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Why Subcision is Needed When Treating Acne Scars with Lasers or Radiofrequency (RF)

Acne scars are routinely treated with laser and RF or RF microneedling. However, the optimal benefits are probably not achieved unless subcision is performed. Here’s why –

Acne scars frequently will have collagen scar fibers extending to the subcutaneous fat, fat pads, or fascial layers. These fibers cause tethering of the dermis, leading to the appearance of an atrophic scar.

FACT: RF and laser energy has a propensity to travel through collagen.

FACT: As energy/heat travels through collagen, it heats the collagen and leads to collagen contraction

Theory: When treating tethered scars, there is a possibility that the collagen contracts and actually makes the atrophic scars appear deeper

Theory: When energy/heat travels down the collagen fibers, some of it might be transferred to the surrounding fat and lead to fat atrophy.

Subcision is a process where the tethered collagen fibers are transected. By cutting these fibers, the energy can’t progress to the deeper layers of tissue and thus not cause possible fat atrophy or further deepening of the scars. I perform this on most patients undergoing laser or RF for acne scarring if I feel there is any degree of deeper scarring or tethering. There is also the benefit of subcision even without using energy based devices in improving acne scars.

The Genius is Truly a Huge Step Forward for RF Microneedling

The initial studies of radiofrequency microneedling (RFM) were performed by Hantash et al. in 2009. What Hantash was able to demonstrate was that RFM produced a fractionated radiofrequency thermal zone (RTZ) with coagulated tissue surrounded by normal tissue. Overtime, multiple growth factors and inflammatory components led to complete replacement of the RTZ with neocollagenesis and neoelastogenesis over the following 10 weeks.

Delivery of the RFM energy varies according to the device used. Unfortunately, there has been a paucity of solid research behind the majority of the devices. There is confusion in the marketplace for both consumers and providers as to what constitutes the best delivery system for outcomes, safety, and comfort. Lutronic decided to breakdown all the components of RFM energy delivery and optimize them in their development of the Genius.

One of the selling points of many of the devices has been that they are comfortable and have minimal downtime. What this actually means is that there is minimal energy delivered to the dermis. Discomfort is directly related to the amount of energy delivered. Lutronic’s research has shown that needle depths and energy settings don’t necessarily correlate to the what really occurs in the tissues.

Needle Depths

Skin intrinsically resists puncture by outside forces. If is especially difficult for 49 needles to penetrate the skin in a small area (1x1cm2). The natural tendency is for the skin to buckle with the needles “bouncing off the surface” and several of the RFM devices tested have been documented to exhibit this phenomenon. Furthermore, needles have a harder time penetrating deeper into tissue than superficially, so deeper depths are even more challenging to accurately place than more shallow treatments. Unfortunately, setting needle depth on the device doesn’t always correlate to actual tissue depth. Requirements for accurate depths include:

Sharp needles – but not too thin as to bend or dull during hundreds of pulses
Powerful motor – underpowered motors prevent accurate penetration
Quick motor – slower motors will lead to pushing the skin rather than penetrate it

Energy Delivery

One of the fallacies of RFM devices is that higher treatment levels correspond to higher energy delivery. Best results will be related to turning the energy settings “all the way up” is ABSOLUTELY FALSE. Too much energy in too short a period will lead to rapid rises in tissue impedance (resistance) and cut off energy flow immediately. Performance by the operator can affect the energy delivered if handpiece pressure is light or not flush with the skin as well.

Tissue Impedance

Impedance in the dermis is highly variable between patients and even within different areas of the face and body. Variables affecting impedance are: hydration, solar damage, collagen and hyaluronic acid content, and scarring. Using settings based on clinical findings and desired outcomes is not enough precision for optimal energy delivery.

Coated vs Uncoated Needles

Coated (insulated) needles allow the microneedles to penetrate the skin and deliver energy to the dermis while bypassing the heating of the epidermis. Some devices will use uncoated needles which will increase the risk of post inflammatory hyperpigmentation (PIH), particularly in darker skin types. To minimize this risk, uncoated needles use low energies and therefore sacrifice results. There will also be more downtime/wound care with uncoated needles because the skin surface will be more affected than with the coated needles.

The Genius Advantage

Proprietary needle design – sharp and coated for minimal resistance to insertion
Improved motor insertion – high torque and quick needle insertion
Improved protocols – changes to energy and pulse durations to avoid sharp rises in impedance based on Lutronic proprietary research
Impedance Feedback – the needles monitor tissue impedance every 2 msec and give feedback to the device to optimize energy delivery and adjust flow as resistance changes. This is the “brains” of the Genius.
Energy delivered feedback – each pulse is monitored and amount of energy delivered is noted. If energy is not exactly as desired/set, both a visual and audible signal is sent to operator. Adjustments in settings or technique can be made to improve energy output.
Total Treatment Energy – a running total of energy given is kept. This allows the provider to base treatments on energy delivered. Cumulative energies delivered from multiple treatments will become the standard of care to achieve clinical outcomes for a given diagnosis.

With the advancements made with the Genius, suddenly, all other RFM devices are now obsolete. Genius delivers a precise, safe, and efficacious treatment for laxity, wrinkles, neck lines, acne scarring, and hyperhidrosis in all skin types.

Treating Post Inflammatory Hyperpigmentation (PIH)

Melanocytes are the cells responsible for the pigmentation in the skin. Their activity can be increased in response to inflammation. When skin becomes hyperpigmented from an injury, it is called “post inflammatory hyperpigmentation” or PIH. This is particularly prevalent in darker skin individuals, where there is more melanocytic activity, but can occur in lighter skin individuals as well.

The widely accepted scale for skin pigmentation types is the Fitzpatrick Scale. The Fitzpatrick Skin Type 1 are extremely light skinned, have blue eyes, and burn extremely rapidly with sun exposure. Type 6 individuals have very dark skin, dark eyes, and tolerate prolonged sun exposure without burning. In general, the type 4-6 skin types are the ones at risk for PIH.

PIH is possible after the following:

Laser procedures (mainly laser resurfacing)
Acne
Surgical incisions
Chemical peels
Burns
Infections
Radiofrequency (Infini is low risk)

The best way to treat PIH is prevention, if possible. Prevention consists of calming down the melanocyte metabolism. The standard recommendations are Retin A and hydroquinones. If there is a procedure a darker skin individual is planning that has risks of PIH, this regime should be started at 3 weeks prior to the procedure. It should be continued at least a month and up to 3 months afterwards. These 2 topicals are also standard therapy for patients with PIH.

Prolonged inflammation after a procedure (more than a week) in a darker skin individual, is a risk for PIH. The practitioner needs to recognize this and treat the inflammation appropriately. If there is prolonged redness of the skin, steroids and/or vascular lasers are needed to reduce this. If infection suspected, antibiotics are needed. Calming the skin is essential to prevent PIH.

The timing of PIH is very predictable. It almost always occurs about 3 weeks after a “at risk” procedure is performed.

If there is already PIH, treatments which can be used are:

Topicals such as Retin A, hydroquinone, and steroids; Triluma contains all 3
Chemical Peels
Gentle laser treatments with a 1064 laser (nanosecond or picosecond)
Possibly PRP with microneedling (experimental but minimal risk)
Antibiotics for ongoing infections
Laser hair removal for PIH associated with folliculitis

In general, PIH is best prevented then trying to treat after it occurs. Recognizing risk factors with certain procedures is the key to success. Treating prolonged redness is often overlooked and must be treated aggressively rather than taking a “wait and see” approach.

What’s The Difference Between Infini, Profound, and Older RF Devices?

The concept of applying radiofrequency energy into the skin has changed in the past few years. The “older” methods use a process called “bulk heating” to apply the energy to the surface of the skin which will diffuse to the deeper layers of the dermis. The deficiencies of this method are:

The heating is not precise, with the depths unknown.
The epidermis is at risk for too much heat, leading to potential for scarring or pigmentation issues.
Subdermal fat is at risk if the heating goes too deep.
The heating is bulk and not fractional, so safety is less.
The highest temperature achieved is about 45 degrees, enough to minimally stimulate collagen.

The progression of technology with RF heating of the skin has evolved to a process that is more precise. Using microneedles, RF energy is able to be placed at desired depths in the dermis. The deeper, fractional heating is much higher than if placed on the skin surface. It enables the temperatures to get to 65-70 degrees C, enough cause coagulation. Coagulation leads to maximal collagen stimulation and tissue contraction. In regards to the microneedles, there are 2 types of needles used: Insulated and Noninsulated. The noninsulated needles deliver energy only at the exposed tips, completely bypassing the more sensitive epidermis. On the other hand, noninsulated needles allow the energy to transmit along the entire length of the needle, creating a wound that includes the epidermis. When the epidermis is heated to point of coagulation, there is wound care and potential for pigmentation and scarring. The only way these uncoated needles get around potential safety problems is by delivering less energy. The advantages of microneedling insulated delivery of RF are:

More precise level of RF energy delivery.
Fractional heating of dermis, which is safer than bulk heating.
Bypassing the epidermis so darker skin types are more safely treated.
Higher energies can be placed leading to coagulation and better collagen stimulation.
Insulation leads to better epidermal protection, less downtime, and potentially higher energies.

The main devices that deliver RF through microneedles with insulated needles are Infini and Profound. There are actually significant differences that might not be apparent to even the most informed providers.

Infini uses 49 needles while Profound uses 10 needles.
Infini can treat at 0.25 mm incremental depths between 0.1 – 3.5 mm while Profound has just 2 possible depths.
Infini’s pulse durations are up to 500 milleseconds while Profound’s pulses are 3-5 seconds.
Infini uses multiple passes to create thousands of coagulation zones whereas Profound uses only one pass.

What does this all mean? It means that the coagulation wounds placed with the Profound are less in number but much larger in size. The downside to larger wounds is that there is longer healing times because the unaffected tissue which is needed to assist in healing is further from the center of coagulation. With smaller coagulation zones as in the Infini, the wound healing is shorter in duration. In addition, the healing in the desired fashion (without scarring) is easier to control with multiple smaller wounds than it is for fewer, larger wounds. The concept of fractional ablation being safer and with less downtime (popularized by the Fraxel laser) loses it advantage as the wounds get larger.

It boils down to: The Infini creates smaller and many more coagulation zones than the Profound which creates larger and fewer zones. Safety and recovery are improved with the more plentiful, smaller coagulation zones of the Infini.

Off Label Uses of the Infini – A Plethora of Potential Treatment Options – Scars, Sweat, Cellulite, Acne, Fat, Breast Lift, Knees, Tattoos

Dr. Weiner Infini Hyperhidrosis treatment

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The Infini is quickly being recognized by the aesthetic physicians as a very powerful tool to tighten facial and neck skin with very little downtime (less than 36 hours). It has also proven to have an extremely low risk profile, with very few long term side effects noted, even in tan or dark skinned individuals. For those unfamiliar with the Infini, please read this blog. In a nutshell, the Infini is a microneedling fraction radiofrequency (MFR) device that coagulates the dermis at various depths (o.25mm – 3.5mm) leading to tissue contraction, new collagen and elastin formation, and overall skin tightening and wrinkle improvement. Dr. Weiner has been using the Infini soon after it was FDA approved and has become the largest user of the device in the US. There have been several off label (non FDA approved) uses of the Infini that Dr. Weiner has been studying that will be discussed below.

Scar Improvement – The Infini causes disruption of the abnormal/pathologic collagen deposition and stimulates new and more organized collagen that more closely resembles the body’s normal collagen. Acne scars have been treated, even in darker skin individuals, with improvements noted. A physician in Korea has a large series of acne scarring patients who have been treated with the Infini showing dramatic improvements. Other scars being studied are stria (stretch marks) and surgical scars (such as tummy tuck and skin cancers).
Hyperhidrosis (Excessive sweating) – The sweat glands lay in the lower part of the dermis and just below it. By heating these areas up to a certain temperature, they can be destroyed permanently. This has been proven by the Miradry device, which uses microwaves to heat up the tissue. There is a very high long term satisfaction rate using this device after undergoing 2 treatments. It’s drawback has been discomfort (requiring blocks with injections) and cost ($3000 for 2 treatments). The Infini can be set to a depth that targets the area of the sweat glands and heat this area up to a point of coagulation (gland destruction). In preliminary studies in axillary (underarm) sweating, Dr. Weiner’s patients have seen improvements with the Infini with less discomfort, no downtime, and at a fraction of the cost. Dr. Weiner’s Press Release about using Infini for Hyperhidrosis.
Acne – Dr. Weiner had been noting that patients whom were undergoing Infini for skin tightening/wrinkles were also noting improvement with their acne. It was postulated that the sebaceous glands, the glands responsible for sebum production (the root cause of acne) were being injured with the Infini treatment. An acne flair is not uncommon after an Infini treatment, and this is caused by inflammation of the sebaceous gland temporarily. Over time, the glands will involute (becomes smaller with less secretions) and lead to the acne improvements noted. Eventually sebaceous glands can enlarge again (unlike sweat glands with don’t have the ability to regrow), so the treatment with Infini turns out to be a potential long term but not permanent solution for acne.
Body Skin Tightening – Areas such as knees and arms are a concern for many patients. Other than surgical correction, which leaves large undesirous scars, there hasn’t been a good solution. Perhaps the Infini can create similar skin contraction and thickening in these areas as it does on the face. Dr. Weiner is studying this on a few select patients.
Fat Reduction – The depth of 3.5 mm is below the dermis in most areas of the body. Using this depth with the Infini, it is possible to target fat, particularly in the submental (below the chin) area and along the jaw line. Many patients have seen improvements in these areas with their Infini treatments for wrinkles on the face and neck. Dr. Weiner purposely will go deep in these areas to coagulate and destroy fat and then go more superficial to tighten the dermis. Slimming the mid and lower face for patients with excessive fat tissue can be manage with the deep depth Infini treatment.
Cellulite Improvement – Using the same rationale as targeting fat, it seems logical that destroying the fat that is herniating would improve the appearance of cellulite. This is still an area of treatment that is more speculation and research is being conducted by Dr. Weiner on a few select patients.
Tattoo Removal – There is evidence that combining fractional ablative lasers with the Q-Switched laser has benefit in removing tattoos. If this is merely causing more of an inflammatory response to enhance the ink removal, then Infini can cause a similar tissue coagulation, but with less risk and downtime than the lasers do.
Breast Lifting – If the Infini can cause tissue contraction in the area of the breast, is it enough to see a noticeable improvement in the position of the breast? A no scar breast lift sounds extremely appealing. Studies will need to be done to see if the Infini can work for this and if so, how many treatments are needed, are touch ups required, and is it’s price justified.

Dr. Weiner is carefully studying the Infini for these off label uses and trying to develop standardized protocols for the medical community. It seems like the Infini’s potential is just starting to be recognized and its future is very promising.

Ulthera (Ultherapy) Questions Answered by Steven Weiner, MD, Facial Plastic Surgeon

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Q: Is it okay to use hand held tightening devices for the face after ultherapy?

A: Hand held tightening devices can be used after Ulthera, but waste of time and money

Hand held devices for skin tightening do very little. You are better off to save the money for skin care products, dermal fillers, or other treatments. The energy the FDA allows for the home devices is so low that they don’t work.

Q: If you currently have fillers like Sculptra can you have Ulthera?

A: Combining Ulthera with Sculptra is the bomb!

Absolutely, you can combine the 2 treatments, Sculptra and Ulthera. You obviously recognize that the 2 do different things, Sculptra fills volume loss and Ulthera tightens loose skin. When done together, they are synergistic, meaning 1+1=3! My blog goes into details about doing both of these, please read. Steve Weiner, MD, Destin, Florida.

Q: Ultherapy Vs. Refirme Vs. Accent XL for Thin Face

A: Don’t bother with Refirme or Accent XL for the face, Ulthera is much more reliable

All the RF devices which try to transmit their energy through the skin are unreliable with very inconsistent or no results. These include: Thermage, Refirme, Accent XL, Pelleve, Venus Freeze, Exilis. The only one worth using from the RF family, at the present time, is the Infini by Lutronic. Please see my blog which goes into more depth on the technology. (I also have another blog about the benefits of Ulthera plus Sculptra.) Ulthera is a very reliable device, placing the right amount of energy at a given level, at all times. No, it does not affect the natural fat of the face. Steve Weiner, MD, Facial Plastic Surgeon.

Q: Which is more effective thermage or ultherapy for tightening skin?

A: Ulthera is far superior to Thermage for skin tightening results

Ulthera reliably places energy in the dermis and SMAS layer. The energy is always above the critical temperature to cause tissue contraction and collagen formation. Thermage is very unreliable in it’s placement of energy through the skin and therefore it’s results are very unreliable (some have results, while most do not). There is a new device called Infini, which uses RF energy like Thermage, but it places the energy very reliably in the dermis and is therefore much more effective than Thermage as well. I consider the Ulthera for tightening the jawline, turkey neck, raising the cheeks and the brows. Infini would be better for the superficial fine lines, lip lines, necklace lines, cheek lines. I used to have Thermage but sold it the same month that I bought Thermage – 3 years ago. I have much happier patients. See my blog below. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Are these results of Ultherapy really true?

A: Ulthera is not a surgical result, but some people don’t want surgery

There is no debate whether or not the energy is delivered by Ulthera to the precise location that the device is made for. Most people, 8-9 out of 10 get noticeable improvements from the procedure. Are they the results similar to which surgery can give? Most of the time the answer is no. But, if you want little or no downtime, want a result that doesn’t leave scars, and has minimal risks (no long term risks), it is the procedure for you. Surgery has it’s inherent risks: bleeding, infection, scarring, anesthesia, need for redo, poor cosmetic results, nerve injury, as well as downtime (up to a month for a facelift). I have written a blog about why I believe that Sculptra and Ulthera are better than a facelift. Steve Weiner, Facial Plastic Surgeon. Destin, Florida.

Q: How Often Can Ultherapy or Thermage Be Applied? Do Repetitive Applications Have Any Side Effects or the Opposite?

A: Ulthera can be repeated in 4-6 months; Don’t bother with Thermage

Repeat treatments with Ulthera will help you keep up with the aging process. There is no exact right answer as to when you should do this. Getting more treatments will only improve the results and won’t be harmful. I have given up on Thermage 3 years ago when I got the Ulthera because results are so much better and more consistent with Ulthera. Read my blog about RF devices and see why Thermage doesn’t work well. Infini is a good skin tightener too and it’s full ability has yet to be determined. Steve Weiner, MD, Facial Plastic Surgeon, Panama City Beach, Fl.

Q: If I Have a Plate in my Neck Can I Still Have Ultherapy?

A: Ulthera can be performed on someone with a plate in their neck

Because the penetration of the energy is only 4.5mm deep, the plates will not be a factor. You can safely have the procedure. Steve Weiner, Destin,FL

Q: 1. Can This Procedure Affect/injure/change the Thyroid? 2. Why is Thyroid Area Avoided During Ultherapy Precedure?

A: Ulthera will not affect thyroid nodules

The thyroid area is avoided because of the cartilage that is close by. It has nothing to do with the thyroid gland. In fact, I could see the Ulthera technology being used to treat thyroid nodules in the future. You have nothing to worry about. Steve Weiner, MD, Destin, Florida.

Q: Can I Get Ultherapy ?

A: Ultherapy for someone who gets cold sores and shingles is ok with prophylaxis

We have done many treatments on patients like you. It just requires taking a dose of Valtrex before and a few doses after to prevent the problem. If you sense that there is an outbreak coming on despite this, take a therapeutic dosing for the recommended time by your doctor.

Q: Can an Ultherapy Side Effect Be Burning and Tingling on Scalp?

A: After Ulthera there is some burning and tingling of scalp, this can be related and will go away quickly

There are nerves in the forehead which travel to the scalp. During Ultherapy, it is possible to bruise these nerves and the result can give you abnormal sensations of the scalp and forehead. To my knowledge, there have been no reported long term issues with Ulthera. This should go away within a few weeks I suspect.

Q: Can Ulthera Be Done on the Neck Only, or is the Lower Face with It Necessary?

A: Ulthera can be done on neck only but not what I would recommend.

Ulthera was recently FDA approved to be done on the entire neck. Best result for the jawline would include the lower face as well to get some lifting above the jawline.

Q: Can Ultherapy Reduce the Size/appearance of Large Submandibualr Glands?

A: Ulthera won’t improve appearance of large submandibular glands

Ulthera won’t get deep enough to hit the submandibular glands. One thing you might consider is having them injected with Botox. I have seen at meetings that Botox reduces the size of enlarged parotid glands so there is no reason why it shouldn’t work for the submandibular glands.

Q: Nurse Squeezing and Tapping Foot During Ulthera?

A: Distracting during Ulthera treatment can decrease pain

The Gate theory goes back to the 1950s which states that the brain has trouble processing two stimuli at once. So when there is a competing sensation, the brain will block out one partially. This leads to less discomfort. We add vibration and cold air so the brain gets really screwed up. Steve Weiner, MD, Destin, Florida, Facial Plastic Surgeon

Q: Thermigen Vs Ultherapy?

A: I have the Ulthera and have seen Thermigen. Please read my discussion to get a better idea.

My clients have been very happy with the results they have seen with the Ulthera. They can walk in and do anything they want to do afterwards. Thermigen is quite similar to the new Precision Tx laser. It requires tumescent anesthesia and requires a chin strap afterwards. It goes under the skin and heats up the fat and skin to dissolve the fat and tighten the skin. It has thermal controls so the skin doesn’t heat up to a dangerous level. I have seen it performed and the patient was comfortable during the procedure. It all boils down to results, and I haven’t seen the “wow” results that would convert me from Ulthera to Thermigen. Thermigen is not FDA approved for this procedure either. The cost of the device is a lot less to the physician than the Precision Tx laser so the procedure should be less to the patient. It depends how invasive you want to be as to which you do. I’m staying with Ulthera for now. If you want more aggressive results, also look at the Precision Tx, which is the same technology as the Cellulaze laser.

Q: Should I Stop Taking Supplements (Eg. Fish Oil, Ubiquinol) After Ultherapy?

A: There is theoretic concern with anti inflammatories after Ulthera

There are no studies to suggest that anti inflammatories decrease the effect of Ulthera but some docs suggest not taking them after the procedure. The risk they say is that the healing process is subdued and therefore you are not getting the full effect of the treatment. I think this idea started with Thermage as an excuse when they weren’t seeing results. I don’t tell my patients to stop these supplements.

Q: Can Have Ultherapy Done Under my Chin and Neck if I’ve Had Cystic Acne Before?

A: Ulthera in patients with prior cystic acne is no problem

Ulthera can safely be performed in patients which have had cystic acne. As Dr. P has said, we don’t do it in the case of an active infection. In the long run, it might actually help the acne by partially destroying the sebaceous glands which are the source of the acne problem. There is an active clinical trial to see if Ulthera can actually be used for acne treatment.

Q: Now That They Have Had the Benefits of Experience Behind Them, Does Ultherapy

A: There have been improvements since Ulthera first came out about 3 years ago.

The changes which have occurred are:

There are now 3 different depths for treatment, 1.5, 3, and 4.5 mm.
There are about twice as many treatment lines being laid down as to when it was first introduced.
Topical lidocaine is being used and having an effect in improved comfort.
Lowering the intensity of the treatment lines give better comfort but same results.

All the above results in more comfort and/or better results (more aggressive treatments). It only makes sense that over time, everyone learns more about the potential of the technology and becomes more comfortable at trying new protocols.

Q: Can You Get Ultratherapy with a Titanium Piece in Your Cheekbone?

A: Ulthera cannot be done in face with Titanium plates

The ultrasound waves will bounce off the metal and scatter unpredictably. This is one of the only reasons someone can’t have an Ulthera treatment.

Q: Had Ultherapy on Upper Face, Had Little Pain, Will It Be Less Results?

A: Very little pain with Ulthera for upper face is a good thing, not bad.

Several measures have been done recently to reduce the discomfort with the Ulthera. A new protocol uses less energy but more treatment lines and seems to have equal results. We also use topical numbing creams and cold air, both seem to help as well. Because protocols are fairly standardize, at least the minimums are, I wouldn’t worry about your treatment. We tend to stay at the upper end of the protocols and give more treatment lines than the norm, but that doesn’t mean it should hurt.

Q: Ulthera After Peel?

A: When Peeling is done after a Peel, it’s ok to have Ulthera

You could probably do the Ulthera immediately after the peel, but because there is liberal use of ultrasound gel, it’s better to wait til the skin is done peeling. It really does nothing to the outer skin, so don’t worry about affecting results of the peel.

Q: Could Ultherapy Be Performed on a Person’s Neck, if That Person Has Some Nodules on the the Thyroid?

A: Ulthera on the neck can be performed on patients with thyroid nodules

The Ulthera (Ultherapy) penetrates 4.5 mm into the skin. The thyroid is much deeper than that, with a layer of muscle between the skin and thyroid as well. There is no worry whatsoever. Dr. Steve Weiner, Panama City Beach, Florida.

Q: How Long After Ultherapy Do I Need to Wait Before Getting Lip Waxing?

A: Waxing after Ulthera (Ultherapy) can be done immediately after treatment

There is no reason to stop doing anything you normally do after Ulthera. There is no downtime. If you use Retin-A or similar, you should wait about 4 days after stopping to get waxed, but this has nothing to do with Ulthera.

Q: Can I Drink Wine the Same Day As Having Ultherapy?

A: Wine after Ulthera is perfect, there are NO RESTRICTIONS

The beauty of Ulthera is that it is a no downtime, fairly risk-free procedure. No long term complications have been reported to my knowledge. Having wine afterwards is quite alright and we encourage people to do their daily routine after Ulthera. There is no data to support this, but some doctors recommend not using anti-inflammatories for about 6 weeks, but we don’t. Steve Weiner, MD, Santa Rosa Beach, FL

Q: Does Ultherapy Work for a Brow Lift?

A: Ultherapy is a noninvasive FDA approved method for Brow lifting

If you desire no downtime and a very low risk procedure to raise your brows, Ultherapy (Ulthera) is a great option. It won’t give a surgical result, but will give a natural look. If you want more results, a second procedure can be done. It takes about 15 minutes to do with only mild bruising or temporary numbness as a side effect.

Q: Aftercare for Ulthera on Lower Face and Neck Yesterday?

A: Aftercare following Ulthera is NOTHING

After having Ulthera, there is no need to do anything special. It is recommended not to use steroids or other anti-inflammatories, but this has yet to be proved to be detrimental to your results (its theoretic). That’s the beauty of Ulthera, no downtime, no aftercare! Please see my video too.

Q: Can I Take a Steroid Medicine (Methyprednisolone) After Ulthera?

A: Taking steroids for a brief period after Ulthera has a theoretical risk of decreasing the effectiveness of Ulthera

Although there are no studies, and it would be very difficult to do a study, there is the feeling amongst some doctors that anti-inflamatories after Ulthera can decrease it’s effectiveness. This is based on the fact that you need the inflamatory factors to produce the collagen and tissue tightening. This would include steroids, motrin, advil, aspirin, but not tylenol. If they can be avoided, it’s advisable but not absolutely. This is a gray area, so don’t worry too much about it.

Q: Does Ultherapy Work for Upper Cheeks?

A: Ultherapy is great for lifting the cheek area

Yes, Ulthera is perfect for lifting the cheek area. Ulthera works by laying down very precise lesions in the skin at 4.5, 3, and 1mm, which over time, leads to collagen stimulation and tightening. Results take about 3 months to fully appreaciate, and some people will want a second treatment. You can see lifting of the brows, improvement in wrinkles around the eyes, lifting of the cheeks, firmer jawline, and tightening of the upper neck.

Q: Ultherapy for Excessive Sweating (Hyperhidrosis Treatment)?

A: Ulthera does work for hyperhidrosis in one study by Dr. Nester

There was a poster presentation at a conference I was at describing very significant improvement in the sweating scores after 2 treatments of Ulthera for axillary hyperhidrosis. The proposed way it works is by destroying the sweat glands with the ultrasound from the Ulthera. It requires lidocaine injections to numb the area treated, just as the Miradry device does. The study was done by Dr. Nester from South Florida.

Q: Can Ultherapy Be Done on the Eyelids? Or is It Not Safe? Or Just Not Tested?

A: Ulthera is not to be used on the eyelids

The company has been evaluating the Ulthera treatment on the eyelids, but as of today, they have not found a good way to shield the eyes from the energy of the treatment. Therefore, it is not recommended to treat the eyelids. Who knows what the future holds though.

Q: What Risks Are Involved with Ultherapy?

A: The risks from Ulthera are mainly some mild bruising and discomfort which is short lived.

Ulthera has been proven to be an extremely safe procedure. According to the company, and our 2 years of experience backs this up, there have been no long term side effects. Some people might experience some mild swelling and bruising right after the procedure, but this subsides rather quickly. Very rarely, some people experience some temporary numbness. With new treatment protocols which are more aggressive, there is slightly more discomfort during the procedure. With topical anesthesia, this has been reduced.

Q: Is It Safe To Do Ultherapy One year Later?

A: Repeat Ulthera treatment is safe and is going to give longer and improved results.

Ulthera is a very safe procedure and there is no risk of repeating treatment after 1 year. In fact, several of my clients have a planned second treatment at 3-6 months after their initial one. The results will be better than just having one, and longevity will be increased.

Q: Ulthera – Are Welts a Normal Side Effect?

A: Swelling / Welts after Ulthera can happen but go away quickly

Occasionally, a person which has Ulthera can have overall swelling which is very short lived. Sometimes bruising can occur and present with firmness under the skin. Visible dermal swelling/welts can occur if the ultrasonic skin injury occurs too superficial. It can occasional have a little fluid like a cyst or pimple, but will resolve within about 5 days.

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

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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

The various treatments for Acne Scars (scarring) at The Aesthetic Clinique

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Dr. Weiner answers questions about acne scars

Acne scarring is a very prevalent problem in our society. It also a very common concern for clients in our office because it most often affects the face and becomes a cosmetic concern. Treatment options are based of the severity of the disease and the intensity/aggressiveness the client desires. One must accept the fact that scarred skin will never improve 100%. However, once a scar in improved, it should persist indefinitely, unless further acne causes more scarring.

UPDATE: We now offer Infini, a radiofrequency microneedling device. This appears to be a great alternative to laser for acne scars. Please read the link.

Topical treatments are needed for all cases acne scarring. The regime should include: Retin A or Retinoid, serum with growth factors (TNS Essential Serum or Lifeline), and sunscreen.

Early scarring, which is the result of recent acne can be treated best with the VBeam. The VBeam will help with the redness and hopefully slow or prevent the progression of the scar turning into a mature and firm scar. The VBeam also helps with future acne breakouts.

Ice pick scarring can be treated with punch excision which involves removing the scar in a sleeve like fashion and closing the skin with a stitch. The more preferred way at our office is to use high concentration TCA and to chemically burn each individual scar in a series of 4 or 5 treatments. This method is called TCA Cross technique.

For more severe global acne scarring, the Fraxel Dual 1550 nonablative laser is probably the gold standard. This laser has more studies and experience treating acne scarring than any other laser. There is some mild swelling for a few days but no open wounds to dress. Peeling occurs for a few days a well. The number of treatments varies according to severity of disease and desired effect, but could be up to 10 treatments. It is safe for all skin types. Ablative erbium or CO2 lasers are used for acne scarring as well but we don’t have these lasers in our office. It’s been our experience that patient’s prefer the less invasive lasers with less wound care. less risk, and downtime.

For minimally depressed scars, using dermal fillers like Restylane can be a quick and easy medium term (9-12 months) improvement. Artefill has just published a study and will probably get FDA approval for acne scars in the near future.

There is research being done for using Ulthera, LaViv, and stem cells for acne scars as this blog is being written.

In general, there are several different choices to treat acne scars. Lasers are required for the most severe cases. Treating acne aggressively to prevent scarring is obviously highly recommended because treating the scarring is much more difficult.