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7/14/2019 5:20:39 PM

While there are number of studies suggesting that lasers and RF do not affect fillers, a recent article by Dr. Weiss opened up the debate again. In his paper he stated that biopsies showed evidence of heating around the filler. It did not evaluated the changes in the filler volume over time. He concluded that the filler was at risk to be affected by the heat. Dr. Davin Lim’s recently published study contradicts Dr. Weiss, and showed with RFM, there was no affect on fillers (biopsy proved) at multiple different energy levels.

The heat from RF Microneedling reaches approximately 65-75 C for 100 msec to up to 3-4 seconds depending on the device and parameters used. This is the “hottest” version of RF delivery used in aesthetics.  This compares to the sterilization process of the fillers at the (Galderma) manufacturing plant of 110-120 C for 15-20 minutes.

Lasers can heat the tissue to a higher level, up to 100 C, but again, it is for milliseconds at best.

Conclusion: There should be no concern regarding placement of HA fillers with RF Microneedling or lasers, at any level of the dermis or subcutanous planes on the same day. Furthermore, there will be no effect on previously placed HA filler. As a side note, PMMA has to be heated to 160 C to cause changes to it’s structure. While the exact temperature is unknown for calcium hydroxyapatite, it is significantly higher than HA, so it too is safe from RF and lasers.



7/14/2019 4:56:33 PM

There is an ongoing debate among injectors as to what method of injecting fillers is more accurate. The needle pundits state that the needle can inject in any tissue, at any depths. While this is true, is the filler actually placed where they think it is? Cannulas aficionados argument is that cannulas will stay in the plane which they are placed, and are therefore more accurate.

In a paper titled “Precision in Dermal Filling: A Comparison Between Needle and Cannula when Using Soft Tissue Fillers.” by Pavicic, Frank, Cotofan, et all, the debate was studied. There were 10 cadavers studied for supraperiosteal injections. The filler injected was radiopaque. Needles were placed in position using a perpendicular transcutaneous approach. The cannulas were placed in a similar position in the supraperiosteal plane. Using fluoroscopy, the injected material was analyzed in the horizontal and vertical planes.

The results show that in over 60% of the needle injections, the material changed planes (became more superficial) and this was not found in the cannulas group.

The conclusion was that cannula filler placement is more precise because the filler remains in the plane of the intended implantation much more so than needle placement.

Article Link



6/26/2019 7:45:28 PM

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.

 



6/20/2019 6:16:31 AM

Cannulas, specifically, blunt microcannulas, can be used to administer fillers by advanced injectors. They a favorable over needles because they have a blunt round tip and are flexible, leading to the following advantages:

  1. Less discomfort – one entry point can serve a large area, thus avoiding multiple dermal penetrations which is more uncomfortable.
  2. Less bruising – the rounded/blunt tip tends to bend around blood vessels rather than nick or penetrate them.
  3. More accurate – a recent study shows that the filler is most likely to be deposited in the area of the exit port vs a needle which has been shown to have filler travel up the shaft (back flow)
  4. Safer – cannulas are less likely to give intraluminal vessel injections because of the blunt tip and therefor less possibilities of vascular compromise and blindness.

However, a recent publication by Drs Pavicic, Cotofana et al. has shown that #4 comes into question with certain cannulas. There study consisted of a total of 294 penetrations of the superficial temporal artery in cadavers using 22, 25, and 27 gauge cannulas and needles. The force applied to enter the vessel was measured for each. The cannulas had statistically higher forces needed to enter the vessel for the 22 and 25 gauge cannulas.

Interestingly, there was no difference in the forces when comparing 27g cannulas and needles.

The conclusion was that a 27g cannula was not safer than a 27g needle when used for filler injections. While 27g cannulas can be used, it is up to the injector to realize these are not safer than needles and to take the appropriate safety measures during treatments.

(Article:   2019 Mar;143(3):504e-512e. doi: 10.1097/PRS.0000000000005321)



6/20/2019 2:52:53 AM

 

There is renewed interest in neuromodulator/neurotoxins because of 2 newcomers to the US aesthetic market. Jeuveau is FDA approved and Revance will be approved early 2020. To differentiate themselves, these 2 have focused on duration of action of their products. Here’s the lowdown on what patients need to know about these wrinkle eradication injections.

There is a well-recognized scale that grades the glabellar lines at full contraction. Grade zero being no lines and 4 being the most severe dynamic lines. Keep in mind that this scale references only lines which appear during motion, not the static lines found at rest. In order for the FDA to approve injectable neuromodulators for the glabellar lines, there must be a demonstrable 2 point improve in this scale after 30 days. The take home messages of these FDA studies are:

  1. The FDA considers a one-point improvement a failure, but the companies do not. There is literature and marketing by several companies stating their 4 or even 5 month duration for one-point improvements.
  2. At FDA approved dosing, most grade 4 glabellar lines will not relax to the grade-zero score. In fact, with any dosing, grade 4 patients will most likely still have movement and wrinkles after treatment.
  3. Not all patients had a 2 grade improvement in the FDA trials of any of the neuromodulators. Approximately 88-92% of patients responded to the FDA approved dosing.
  4. The effect of muscle relaxation peaks at about 2-4 weeks, and then gradually tapers off. Muscle strength eventually returns to baseline at 3-6 months, depending on the dosing and the product used.
  5. At 3-4 months, the FDA approved duration of the current modulators, a minority of patients still have 2 grade improvements in their glabella grade.

A well-established phenomenon with all the neuromodulators is the dose-response curve. The higher the dosing, the more effective the relaxation of the muscle injected. Additionally, the higher the dosing, the longer duration of the relaxation. Dr. John Josephs has performed studies on Dysport using dosing of 120 units (FDA approval is 50u) and has shown up to 6 months of 2 grade improvements in a significant proportion of patients. One “trick” he used when using these higher doses was to minimize the reconstitution volume to only 1cc. (Most practitioners use 1.5-3cc). Dr. Joseph refers to this technique as “A big dog on a short leash”. In other words, high dosing with limited spread in order to limit adverse events.

An as yet to be approved neuromodulator from Revance will be after a 6 month approval of their product. While at first glance, their 40 unit dosing will appear to be using the phenomenon of higher dosing – longer duration, this is not the case. Neuromodulators units, unfortunately, are not uniform between companies. A study Revance performed on the actually molecular weight of the active neurotoxin in their dosing showed that it was equal to that of the 20 unit dosing of Botox. They also evaluated Dysport’s weight, which was shown to be 50% higher than Botox and Revance, while Xeomin was actually 50% less than Botox/Revance.

What makes Revance’s neuromodulator last longer? It’s an associated proprietary protein that does not dissociate upon reconstitution. It is hypothesized that this protein’s ionic charge leads to better attraction to the receptor at the neuromuscular endplate. Revance’s product is essentially “more efficient” at binding, and therefore blocks more of the muscle movement than the other neuromodulators on the market at FDA approved dosing. Normally, there is some “wasted” neuromodulator which doesn’t bind and is swept away by the lymphatics and blood stream. The proprietary protein mimics what higher dosing would accomplish.

Neuromodulators work by blocking the release of acetylcholine at the neuromuscular endplate of the nerves. Return of function of the muscle is established when new nerve fibers are grown and re-establish contact with the muscle. If more nerves are blocked, it will take longer for the return of muscle function. If all the endplates were blocked to a muscle, studies have shown it takes 9 months for return of function.

After explaining all the numbers, it must be remembered that each patient reacts differently to the neuromodulators. As previously explained in another blog, once water/saline is added to the vials of Botox/Dysport/Xeomin/Jeuveau, there is only active protein in the vial within about a minute. The differences between the products are related to dosing, spread, and experience of the injector. As previously mentioned, Dysport has the highest weight of active neurotoxin in its FDA approved dosing and is the author’s choice amongst the current FDA approved neuromodulators.



6/20/2019 2:42:08 AM

The aging phenomenon affects all the areas of the face and body. Sun exposed areas will be most affected due to the collagen destroying effects of UVA and UVB light. Dr. Weiner has developed a technique which addresses many different aspects of the aging neck, and, better yet, it’s all minimally invasive.

Pigmentation

Hyperpigmentation is a sign of UV damage and aging. It can be addressed with nonablative lasers, such as the Thullium 1927nm laser (Fraxel Dual/LaseMD). In some patients, there is also an associated redness, such as in poikiloderma. Redness needs a vascular laser such as the Excel V + laser. Skincare products are essential in maintaining results and must include a retinol, growth factor, and SPF.

Volume Loss

Much has been written about fat loss in the face, but this process will also affect the neck. Recent articles have validated safety with collagen stimulating fillers in the neck if done with careful technique. Deeper lines and wrinkles might also require a hyaluronic acid filler (HA) for improvement

Laxity

Loss of collagen, elastin, and gravity contribute to skin laxity in the neck. Radiofrequency seems to be the leader of the pack for tightening skin and building collagen and elastin. There are a couple different methods to use RF in the neck such as The Genius, FaceTite/NeckTite/AccuTite.

Hyperactive/hypertrophic Platysma

There is more literature supporting the platysma muscle becomes stronger as one ages. This leads to neck bands, jawline sagging, and corners of the mouth drooping. Strategic placement of a neuromodulator in the platysma can improve the appearance of the jawline and neck.

Excessive fat

Fat can accumulate in the chin area (double chin) and along the jawline. Methods used to improve the appearance of the fat in these areas includes: Kybella, Genius, FaceTite/NeckTite/AccuTite. If these procedures are done, the other procedures listed above will have to done on a different treatment day. Jowling can also be improved with these methods.

 

By combining these treatments, usually done in a series, multiple areas of the aging process can be addressed. Upkeep with future treatments and skincare is essential to maintain long-term results. To see if Dr. Weiner’s “TriNECKta” treatment is right for you, please call the office: 850-622-1214.

 

 

 



5/24/2019 12:10:44 AM

The aging process leads to hyperactivity of the muscles of the face. This movement leads to increased wrinkles and loss of the smooth, youthful appearance of the skin. In the upper face, neuromodulators such as Dysport and Botox, do a great job at relaxing this hyperactivity. What’s trending with aesthetic providers is dampening the muscle movement but not complete relaxation, leading to a more natural expression without “freezing” the patient.

Unfortunately, the neuromodulators can’t be administered throughout the entire face. In the lower face, low doses of neuromodulators are safe for the lips, chin, gummy smile, and DAO (AKA RBF) muscles for the most part. Inhibiting the lower face too much leads to changes with expression and smiling. What can be done to control the muscles in this area? Filler!

(Side note: Hyperactivity of the lower face has been described by Dr. Weiner in gum chewers in a previous blog. It leads to accelerated aging in the lower face and should be discouraged by aesthetic providers.)

An interesting study by Dr. Nowell Solish supports this concept. Using a rather large and sophisticated machine, Dr. Solish was able to determine muscle strain in the lower face during facial expressions. He compared patients in their 50’s to ones in their 30’s. As expected, the older patients had more muscle strain than the younger patients. He then injected the older population with Restylane Refyne and Defyne, 3-4cc in the perioral area. These fillers have XPresHAn technology and have flexibility – stretch capabilities. After the injections, the older patients were restudied for muscle strain. The findings: The muscle strain of the 2 groups (older vs younger) were basically the same. The filler was able to reduce the muscle strain about 15 – 20 years!

What’s the explanation? Dr. de Maio has coined the term myomodulation. His theory is that filler placed around hyperactive muscle leads to stretching and relaxation of the muscle. While this is plausible, there is probably a better way to describe this phenomenon.

Dr. Weiner’s theory: Think of an Aston Martin that has a top speed of 230 mph or more. However, in the US, to conform to the laws and regulations, governors are placed on the car to keep its top speed at 180 (This is purely hypothetical and used for illustrative purposes only). Dr. Weiner feels the fillers Refyne/Defyne limit the full range of movement of the hyperactive muscle, akin to a governor on the muscle. Why these fillers work so well at doing this is because they can stretch and recoil (akin to a tether), leading to some, but not excessive muscle movement. Other fillers would work but with a different and less natural mechanism. Think of the non-flexible fillers as acting as a wall, and not as a governor or tether.

With the new XPresHAn fillers, Refyne and Defyne, we now have a new treatment modality for the lower face which is highly effective. Myomodulation is real, exactly what is the underlying mechanism is still debatable.



5/13/2019 1:14:38 AM

Dermal fillers are becoming increasingly popular worldwide. Contouring of the face, restoring volume loss, enhancing features such as lip plumping can all be obtained with very little downtime. Just 15 years ago, surgery was the only way these enhancements could be performed. There are some minor complications associated with fillers such as pain, bruising, swelling which are fairly common (>70%) and some major risks such as vascular occlusion, blindness, and stroke which are much less common.

The most common method to administer fillers is using the needle which is packaged with the product. While needles are very easy to use, in the author’s opinion, they are more risky and lead to more downtime versus the blunt microcannula technique. Microcannulas were introduced to the United States about 8 years ago from Europe. These were a smaller version of the already widely cannulas which were used for fat transfer. When compared with a needle, cannulas are more flexible, longer, and their tip is more rounded. The following advantages are found with cannulas:

  1. Fewer dermal penetrations – cannulas are introduced through only a small number of pilot holes.
  2. Less discomfort – the dermis contains more pain fibers  than the deeper tissues. The injections with cannulas are below the dermis, so discomfort is less.
  3. Less trauma to tissues/less bruising – because of the rounded tip, the cannula is less likely to nick blood vessels leading to less bruising and swelling.
  4. Faster procedure times – With an experienced cannula user, placement of filler is done very quickly and efficiently. (Cheek/tear troughs <5 minutes per side, lips <5 minutes)
  5. Less vascular occlusion risks – While cannulas aren’t 100% safe, the risks of injecting into a blood vessel are less because entering a vessel is more difficult with the rounded tip and flexible shaft. This is true for the larger gauge cannulas such as 22, 23, and 25. Recent studies by Dr. Pavicic and Cotofana have shown the 27g cannulas have the same force needed to enter a vessel as a 27g needle and therefore should not be used.

Galderma recognized the advantages of microcannulas and became the first company to get FDA approval for their use with Restylane Silk in lips in 2017, and for Restylane Lyft for the cheeks in 2018. While less than 10% of providers use cannulas in the US, there is a push by the top injectors to encourage their widespread use.

Dr. Weiner has been using microcannulas since 2012 and is one of the most experienced cannulas injectors in the US. He is one of the leading trainers for Galderma, particularly for their cannula trainings. He is available for private trainings in off label use of fillers – face/body. There are shadowing opportunities as well as week long internships opportunties. For inquires, please email: info@theclinique.net or steve@stevenfweiner.com



5/3/2019 8:25:02 PM

The most popular cosmetic procedure in the world is wrinkle reducing injections with neurotoxins or the friendlier term, neuromodulators. The injections work by reducing the activity of the muscles they are injected to, there by resulting in less movement and less dynamic wrinkles. Static wrinkles, ones that appear at rest, are less affected by these injections, but over serial treatments, improve as well.

The history of neuromodulators dates to the isolation of the botulinum toxin, the cause of botulism, in the 1928. It was later refined and made commercially available for injections in the 1989 and initially FDA approved for strabismus, lazy eye. Soon thereafter, blepharospasm, spasm of the muscles around the eye, treatments were approved. The team of Carruthers and Carruthers observed that during blepharospasm treatments, the wrinkles around the eye, crows feet, were also improved. Studies were later performed on the frown lines, and FDA approval for cosmetic use was achieved in 2002.

There are currently 3 FDA approved neuromodulators of botulinum toxin A for cosmetic use: Botox, Dysport, and Xeomin. They all work similarly by blocking the acetylcholine release at the neuromuscular junction. Each brand has their own definition of what a unit dose is, so this can be confusing to both the practitioner and the patients. The differences between the 3 is the associated inactive protein, or absence of this protein in the case of Xeomin. Studies have shown that once the drug powder is mixed with water or saline in the provider’s office, the inactive protein disassociates almost immediately. Why then, are there differences in clinical outcomes between the 3 neuromodulators?

There is a recent comparison of the active protein molecule in the 3 products dosing in the glabella. The study looked at the FDA approved doses for frown lines – glabella. A very interesting finding was that there was 0.27ng in Dysport using the 50u dose vs 0.18ng in Botox’s. Xeomin was a distant 3rd coming in at 0.08ng with their 20u dose. In essence, patients are receiving a stronger dose when using Dysport when compared to Botox or Xeomin.

It’s long been established that Dysport seems to be effective (in 1-2 days) sooner than Botox (3-4 days) but the reason was never clearly elucidated. It’s also well known that higher dosing of any of the neuromodulators will lead to longer durations of action. This higher level of active protein with Dysport can explain the clinical phenomenon of quicker onset and longer duration.

One other topic needing addressing is the myth of higher diffusion with Dysport vs Botox. Diffusion or spread, is a result of dosing, volume, speed of injection and not a function of the neuromodulator. As stated before, when reconstituted, all the products are free of their associated proteins and only consist of free, active protein. We now know that Dysport has more active protein in their approved dosing, so to compensate, lower volumes must be used for reconstitution. The author’s recommended reconstitution for Botox is 2cc and for Dysport is 1.5cc for the glabellar injections. When diffusion or spread is desired, larger volumes can be used.

With the recent comparison study of active protein in the dosing schemes of the 3 commercially available neuromodulators, it is easy to see why Dysport should be the standout choice. Dysport gives more effective treatments because of the higher active protein, leading to quicker onset and longer duration (up to 5 months) than Botox and Xeomin. Pricing is usually less with Dysport, so it becomes a “no brainer” 1st choice for Dr. Weiner’s practice.



4/14/2019 3:38:55 PM

Acne scarring has significant debilitating effects on one’s overall self-worth and confidence. Millions in the US are affected. There have been improvements in techniques and energy devices in past few years which have led to better outcomes for acne scar treatments.

Subcision – This is process of breaking up deeply tethered scar bands associated mainly with atrophic/rolling scars. Subcision has be performed for acne scars for decades and just using this procedure alone has proven to lead to significant acne scar improvements. Recently there have been a couple publications suggesting that cannula subcision had better outcomes, less downtime, and less discomfort than the traditional method of using a Nokor needle. A cannula has a blunt tip so it is also safer – less chance for cutting a nerve or blood vessel than the knife-like edge of the Nokor needle. In the study, both patients and the performing doctor rated the results better when using the cannula. Subcision is particularly important, in Dr. Weiner’s opinion, to be performed prior to any energy device for tethered scars. This is based on the fact that RF and laser will preferentially travel through collagen – which is high is water content – than fat or most other tissue. Scars are predominantly collagen, so it makes sense to cut the connection of the scar to the deeper tissue. Through personal communication with Dr. Davin Lim, biopsies he performed have shown scar band that reach the deeper fat pads from tethered acne scars. Transmission of the energy through the scar can theoretical lead to collagen contraction and deepening of the tethered scar. Sometimes fillers are placed at the time of the subcision to improve the volume loss associated with the scarring. Some hypothesize that putting a “spacer of filler” might improve results as well. Dilute lidocaine during the initial passes allows for this procedure to be well tolerated.

TCA CROSS – TCA (Trichloroacetic Acid) is a chemical peel used to improved acne scarring by placing minute quantities in the scar using a toothpick. CROSS stands for Chemical Reconstruction of Skin Scars. The most common use of this procedure is for ice pick and small boxcar scars. The process of causing a controlled chemical burn, allows for the body to heal from the deepest part of the scar towards the skin surface. This makes the scar smaller in diameter and shallower. Usually a series of 3-6 treatments are needed, with 3-4 weeks between treatments. There will be some mild scabbing for a few days which needs to be kept moistened for best results. Risk include widening of the scar or post inflammatory hyperpigmentation (PIH).

Radiofrequency Microneedling – This technology (RFM) has been available in the US for about 6 years and has revolutionized acne scar treatment. Using needles which are insulated, energy is delivered into the scar tissue directly and bypassing the epidermis, for the most part. The insulation protects the skin surface from heating so darker skin type individuals are at much less risk of PIH (post inflammatory hyperpigmentation) vs a laser treatment. The needles allow for deeper penetration than lasers as well. Overall, downtime is less than ablative lasers in most individuals (when insulated needles, proper technique, and appropriate settings are used). With acne scarring affecting darker skin types disproportionately, this is an excellent alternative to lasers. The Genius has recently been FDA approved and is now the “best of bread” RF microneedling device. There is now impedance feedback from the needles which allows for improved and exact energy delivery. The resistance in the tissues being treated is measured and this is important because throughout one’s face, there are differences, as well as between different individuals. Also, as tissue are heated or subcised, the resistance changes. Prior to Genius, there was no idea of how much energy was being delivered. There is now an accurate total energy for each pulse and a cumulative total. Other improvements include needle design-sharper, stronger motor, and feedback regarding quality of each pulse fired.

There is a myth that needs to be busted. Deeper does not mean better for acne scars.

The needles must stay within the scar for best results. If the needles go beneath the dermis, there is a risk for heating the fat and fat loss. Let it be known that the actual depth of the needles in most RFM devices is less than the settings, and becomes less accurate, the deeper the settings are. There is inherent resistance of the skin to penetration and many needles aren’t sharp enough or motors aren’t strong enough to get to the desired levels in the time required. This has also been addressed with the Genius and it’s depths are very accurate after extensive testing.

In addition, higher energy levels on any device which doesn’t monitor impedance, can actually result in very little energy delivered. Once the tissue is heating beyond a critical level, the resistance becomes so high that energy output cuts off. However, when higher energy levels are desired when using the Genius, the energy is adjusted to the increasing impedance and it is successfully delivered.

Fillers – Fillers are a very integral part of improving acne scars. They are extremely useful for the atrophic scars and the lipoatrophy associated with these scars. The aging process leads to dermal thinning and fat atrophy, which makes the acne scars appear worse, even if active acne has long been controlled. Fillers need to be injected deeply for correcting large areas of volume loss and superficially in minute quantities for focal defects. A hyaluronic acid filler will give about 12 months of improvement vs Bellafill which can give near permanent improvements. Bellafill does require a skin test to see if one has a allergy to the bovine collagen (0.5% chance) which needs 3-4 weeks to determine. There is some who feel fillers in areas of subcision will prevent re-adhesion of the scars. Most failures from other treatments are related to not recognizing the need to fillers to improve the acne scars.

Lasers – Erbium/CO2 ablative lasers still are beneficial for acne scars but have more downtime and risks vs RFM. Deeper skin imperfections are not improved with lasers and require fillers. These devices are best reserved for more superficial scars, mainly boxcar scars. Non ablative lasers are less affective but safer and in the author’s opinion give very minor results.

Microneedling – Also know as “Collagen Induction Therapy” CIT, has become popular in recent years. There are rollers available for home use and then there are medical grade devices which go to depths of 2mm or deeper and create thousands of penetrations per second. Rollers should be not be used at home for 2 reasons – questionable sterility at home and they tear tissue more than the in-office devices. Often these treatments are combined with topicals and PRP. It is highly recommended to not use any products on the skin which would normal not be injected. There have been many cases of infection and granulomas from these practices. Even when done in the office with PRP or amniotic membrane products, the efficacy of this procedure is minimal, and should be reserved for only mild acne scarring.

PRP/Amniotic membrane products – There is some date to support that better results and faster recovery with less side effects if PRP or amniotic membrane products are used during acne scar treatments. There is a movement more towards amniotic/placental products and away from PRP because there are more growth factors/healing properties in these vs PRP.

LLLT – There is a plethora of studies to suggest that using low level laser light (LLLT) is beneficial to results and healing times. The most researched device is Healite, and this should be performed immediately following all acne scar procedures which use energy devices. It calms the skin and improves circulation.

Acne scarring procedures are continuing to improve as technology and techniques evolve. One must understand that results require months to fully appreciate and multiple treatments (3-5 or more) are often needed to optimize results. Expectations need to discussed with providers/patients so that all are on the same page as to what one can achieve with treatments.

Dr. Weiner is an Acne Scar Center of Excellence designated by Bellafill and is a specialist on acne scars. He is a lecturer and trainer for Bellafill. He has become one of the leading authorities on Radiofrequency Microneedling and travels the globe lecturing on this technology. He performed the FDA trails for the Genius. He recently authored a chapter on RF Microneedling which soon will be published in the Facial Plastic Clinics of North America. He also wrote a recent chapter on Radiofrequency Safety and Complications which will be part of a book titled “Complications in Minimally Invasive Facial Rejuvenation: Avoidance and Management” by Paul Carniol, MD



1/29/2019 7:02:02 PM

It appears that 2019 is the “Year of the Jawline”.  A strong jawline is interpreted as a characteristic of strength, beauty, virility, and power. In a study of S&P 500 CEO’s, 95% were considered to have a well defined jawline.  With advances in aesthetic technology and techniques, achieving that perfect profile is becoming easier, with less downtime, costs, and risks. Here are the top 5 procedures to improve your jawline:

5) Neck Lift/Lower Face Lift: With incisions placed behind the ears, this surgery can be performed with just local anesthetic. Downtime is about a week or 2. For severe jowling and platysma bands, this will give the best results.

4) Ablative Laser (Erbium/CO2) or Renuvion(J Plasma): These procedures have significant wound care for a week or more. The skin is stimulated by the heat of the laser/plasma to contract and create collagen. Healing time can take weeks and redness can persist for months. Risks include infection, scarring, hyper and hypopigmentation. Procedure is limited to the face, and can’t achieve fat reduction.

3) FaceTite: A minimally invasive procedure whereby radiofrequency is placed below and on the skin surface. Requires tumescent anesthesia only for most patients. Procedure takes about an hour, more if liposuction is added. There is minimal bruising and swelling afterwards but requires a compression chin strap for a few weeks (constant for the first 48-72 hours). The RF energy causes deep collagen stimulation and contraction as well as dermal collagen remodeling. Jowls and submental fat can be attended to with RF and liposuction.

2) Genius/Infini: Radiofrequency is placed into the dermis (and subdermis for jowls/submental) using insulated microneedles.  The downtime is 2-3 days but it requires 3 treatments. The procedure takes about 30-45 minutes. Most patients require just topical anesthetic with about 5-10% opting for Pronox (Nitrous Oxide – laughing gas). Results take 3 weeks to start to become apparent and 3 months for their full effect. It is the least downtime, least invasive of the top 5 procedures, outside of #1.

1) “reJAWvenation(TM)”: Using microcannulas, filler is placed along and below the jawline to enhance and restore the profile. Typical procedure time is 10 minutes or less and there is no downtime. The amount of syringes required varies, but can be anywhere from 1-6. Multiple sessions are required for the patients with severe jowling. While there is no actual removal of fat from the jowls or submental area, these areas appear improved due to the lifting by the filler as well as camouflaging the trouble areas.

It is left up to the individual as to what procedure is right for them. Lifestyle, degree of correction desired/needed, and finances all factor into one’s decision making. Dr. Weiner is world renown for his “reJAWvenation(TM)” procedure and is known as the reJAWvenator.

 

(Threads are notably absent because the author believes the expense, duration, and results, don’t warrant them to be a consideration for jawline improvement.)



12/10/2018 1:10:15 AM

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:

  1. Sharp needles –  but not too thin as to bend or dull during hundreds of pulses
  2. Powerful motor – underpowered motors prevent accurate penetration
  3. 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

  1. Proprietary needle design – sharp and coated for minimal resistance to insertion
  2. Improved motor insertion – high torque and quick needle insertion
  3. Improved protocols – changes to energy and pulse durations to avoid sharp rises in impedance based on Lutronic proprietary research
  4. 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.
  5. 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.
  6. 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.

 



11/25/2018 4:44:41 PM

Removing hair using a laser dates back to 1995, when the first laser was FDA approved for this purpose. The LightSheer laser (Diode) was approved in 1997 and has been the most popular laser for hair removal since then. About 6-7 years ago, the LightSheer Duet was developed for faster and safer treatments and was the laser used by the author for the past 6 years. The Alexandrite (855nm) wavelength has been consider possibly a more effective laser for hair removal, but it’s limitations have been pain and speed. In addition, both the Diode and Alexandrite laser aren’t considered safe for the dark skin tones where a 1064 (Nd:YAG) laser is needed. The Splendor X has solved all these problems and is now the most innovative laser for hair removal on the market.

The concept of laser hair removal was invented by Dr. Rox Anderson from the Wellman Institute at Harvard’s Mass General.  To permanently remove hair, the hair germinal cells must be killed.  This is done by using a laser whose wavelength matches the pigment of the hair.  The heat absorbed by the pigment travels to the germinal cells and permanently injures them.  In the growth phase of a hair cycle (one of 3 phases of the life of a hair), the hair is attached to the germ cells so the heat is effectively transferred to them.  In the other 2 phases of the hair cycle, the heat will not lead to killing the germ cell.  This is why several treatments are needed, so as to eventually hit most of the hairs in the growth phase.  One should expect about 75-85% hair reduction after 6 treatments, and the need for touch ups, 1-2 times per year.

What makes Splendor X different?

Dual (Blended) Wavelengths: Spendor X has both the Alexandrite 855nm and the Nd:YAG 1064 wavelengths. It can safely treat all skin types. For the lighter skin, mostly the 855nm is used. For darker skin, the laser uses a blend of the 2 wavelengths while in type 6’s, only the 1064 is used. While some companies had 2 wavelengths on their device, it is either one or the other, and not a synchronized output. The benefit of the 1064 laser for lighter skin types is that it penetrates deeper than the 755 laser and can attack deeper hair follicles as well as the vasculature feeding these follicles.

Square Footprint: The pulse from the laser is uniquely square. This overcomes the uneven treatments which are inherent in the typical circularly outputs. With the circular footprints there will be potential for skipped areas and/or over-treated areas from overlapping pulses. The Splendor X has a glow-in-the-dark marking system to guide the operator to place pulses abutting each other with minimal overlap.

Double Cooling System: The Splendor X uses both integrated Zimmer Air Chilling as well as a chilled tip to doubly ensure a safe treatment. By chilling the skin surface, the laser will preferentially heat into the deeper dermis where the hair follicles are and is less likely to be attracted to skin pigment (less burn or PIH risk).

Highest Speed: Improvements in speed was one of the major attributes to the LightSheer Duet. It could do a man’s back in about 15 minutes, down from the 45-60 minutes it took previously. With the Splendor X, we can now do the back in about 6 minutes with the same or more safety.

High Power: There is higher power than most lasers with the Splendor X – 75% more – 7 Kw vs 4 Kw. Higher power equates to more efficient treatments, more results, less sessions needed.

Plume evacuation: There is a built in suction to remove the plume of the the vaporized hair. Besides removal the smell, this is important as we learn there are possible negative side effects from the plume.

There has been a lack of innovation in the laser hair removal arena for years. Now the Splendor X leaps to the front of the line with its innovative blended wavelengths, square footprint, and lightening speed. Patients can be confident they are receiving a highly effective, comfortable, and quick hair removal treatment.



11/18/2018 9:13:21 PM

Acne scarring is a significant psychologically debilitating disease affecting millions in the US, approximately 1% of the adult population in one study. Treatments for acne scars include:

  1. Lasers
  2. RF Microneedling
  3. Fillers
  4. TCA Cross
  5. Subcision
  6. Microneedling
  7. PRP (Platelet Rich Plasma)
  8. PDO Threads (?)

Most of these techniques are based on trying to make the disorganized collagen in the scar to be more organized and natural. Using carefully induced tissue trauma with heat or microneedles (mechanical), the body initiates a healing process to smooth the scars.

Acne scars will often affect tissues deeper than the dermis. Fibrosis/scarring can affect the subcutaneous tissues and fat and lead to tethering of scar to the deeper structures. Lipoatrophy (fat loss) can occur as the result of the inflammatory mediators released from the acneic process. When heating from lasers and RF is applied, it is preferentially conducted through the collagen because the water content of collagen is high. Heating collagen will lead to collagen remodeling but also collagen contraction. If the collagenous attachments to the deeper tissue are not cut (subcised), there is actually potential for worsening the appearance of the scars with these heating devices.

A recent paper suggested that using a cannula to subcise acne scars is better tolerated, with less adverse events, and judged to have better results by the patients. This is Dr. Weiner’s (and acne scar expert Dr. Davin Lim’s per personal communication) preferred method of subcision vs using a Nokor needle. By subcising, the energy flow to the deeper structures is severed and harm to fat is less as is the risk of pulling some scars deeper. Placement of filler (Restylane Defyne, Bellafill) is often done simultaneously with the subcision to help elevate the scars and prevent reattachment of the scars.

Subcision has been around for decades for acne scar treatment. It is now even more important when energy devices are used to maximize the benefits of these treatments. The use of cannulas for this procedure leads to more comfort, less risks, and better satisfaction.

 

The Aesthetic Clinique has been designated an Acne Scar Center of Excellence by Suneva (Bellafill) and is considered an acne scar expert.

 

**(Subcision is also useful for treating cellulite as there are fibrous attachments from the skin which cause the dimpling.)



8/26/2018 2:30:28 PM

People chew gum to help clean their teeth after eating, freshen their breath, and even try to keep them whiter. What isn’t readily known is the havok gum chewing has on the aesthetics of the lower face.

The simple act of excessive chewing will lead to muscle hypertrophy of the masseter. Enlargement of this muscles leads to squaring of the lower face and jawline, an undesirable shape in females. The aesthetically pleasing lower face is V-shaped or Heart-shaped. Widening of the lower face is particularly prevalent in the Asian population where the women go to great lengths to slim their face with cosmetic procedures, including surgery. Gum chewing leads to similar problems which fortunately can be reversed with weakening of the masseter muscles with Botox/Dysport.

A much more problematic issue to fix is the negative side effects which occurs around the mouth secondarily to gum chewing. The movements of the soft tissue and perioral muscles is significantly more when chewing than in a relaxed state. Just as with the frown lines and crows feet, the more movement in these areas, the more wrinkles and etched in lines are created. (Ever notice Kim Kardashian doesn’t smile in pictures? It’s because she’s afraid of creating wrinkles, so she limits her facial movements.) In essence, gum chewing accelerates the aging process around the mouth and lower face. Unfortunately, Botox/Dypsort aren’t as easy a remedy for this area because restricting muscle activity can lead to eating and vocalization difficulties. However, lasers, radiofrequency, microneedling, and judicious use of Botox/Dysport can improve the perioral aging process.

Straws can also lead to upper lip lines due to excessive muscle use of the lip muscles (orbicularis oris). The recommendations to improve lower face and mouth asethetics: stop gum chewing and straw use and consider breath mints as a substitute.



6/2/2018 2:06:16 PM

It’s been the dream of generations. Hundreds of machines have failed. Now there is Emsculpt. It is now possible to strengthen your abdominal muscle muscles effortlessly and pain free. How about lifting and shaping the buttocks without squats? In fact, you can drink wine, eat a donut, or watch a movie while this is happening – NO JOKE!

The science behind the device is fairly simple to understand. The Emsculpt uses electromagnetic waves to stimulate the underlying muscle. Think of the TENS unit that is used to improve aches and pains, ON STEROIDS. The contractions are “supramaximal”, meaning more intense than a person can do on their own. During a 30 minute session, the abs/buttocks contract equivalent to a workout of 20,000 crunches/squats. The usual protocol is to have a total of 4 sessions in 2 weeks. Expect some muscle soreness the next day or 2 but there is essentially no downtime. Better yet, there is really no risks either. There are 2 handpieces for each machine. This means that 2 patients can be treated simultaneously on the abdominal area or one patient on the buttocks area.

There were 7 different sites that studied the Emsculpt. Before and after CT scans, MRIs, and Ultrasounds were taken in the study group. Results showed muscle mass increased 16% consistently. What is even more interesting is that the average fat loss was 19% and waist measurements decreased by 4 cm.

Another treatment area is the gluteal area. Using 2 handpieces simultaneously, the buttocks is treated. The settings are adjusted so as to not cause any fat destruction but just muscle hypertrophy. Other areas being treated experimentally by some physicians are the thighs and calves. The pectoralis muscles definitely can’t be treated because they are too close to the heart and the strong electromagnetic waves might stimulate the heart.

There have been anecdotal reports of enhanced athletic performance after Emsculpt treatments. Is this a new legal way to get an edge on the competition?

Contraindications are people who have pacemakers, metal IUDs, metal implants or surgical clips (close to the treated area).

Bottomline, six pack abs and brazilian butt lifts can now be obtained using the noninvasive, risk free, no downtime, Emsculpt.

Call The Aesthetic Clinique for more details, the Emsculpt headquarters of the US.

850.622.1214



3/27/2018 3:00:42 AM

Dermal fillers improve volume loss or enhance facial features. Their use is increasing at rate of 10% or more per year worldwide. Adverse events are usually minor  and consist of bruising, swelling, asymmetries, and nodularity. More significant complications are fortunately rare and include infection, granuloma, skin necrosis, and blindness. This blog will concentrate on techniques to minimize the risks of having a vascular event.

There are 2 ways a blood vessel can become occluded. If an artery is entered and filler is injected within the lumen (Intraluminal), filler will travel down the vessel until it gets lodged. At this point, the filler stops the flow of blood to areas which are dependant on this blood supply. Smaller pieces of the filler can break off and flow into areas far from the initial injection and into the very small arterioles. There are theories that an inflammatory response/cascade exacerbates the injury to the skin and dependent structures. This is Dr. Weiner’s opinion for the etiology of the majority of vascular occlusion cases.

A second way a vessel can occlude is if there is external compression of the vessel by filler. This is plausible in areas of compartmentalization, such as in the nasal tip. If the pressure within the nasal tip exceeds the pressure within an artery, flow will stop. Unfortunately in this area, vascularity is so poor that peripheral flow doesn’t occur. External compression is not a major problem in most areas of the face in Dr. Weiner’s opinion. Most vessels can be ligated during surgery and there is no resultant skin necrosis – proving that peripheral flow can make up for an externally compressed vessel.

The worst cases of vascular occlusion result in blindness. This is the result of a filler embolus that travels through an anastomosis between the external and internal carotid systems. The filler backs up into the central retinal artery which feeds the retina. Blood flow is blocked to the retina and blindness ensues.

In most cases, early recognition of a vascular event can be reversed with hyaluronidase if a hyaluronic acid filler was used. Minimal or no sequelae are seen if action is taken within the first 4-6 hours. Unfortunately, even immediate action for blindness related to a filler complication, has little or no success.

There have been about 100 reported cases of blindness from fillers, with most of the cases coming out of Asia. This is certainly underreported though. The areas of most risk for blindness are injections in: glabella, nose, periocular, and NLF. Fat is the most common filler causing blindness, but all fillers have been implicated. Any area of face is at risk for vascular occlusion/necrosis.

The key to avoiding vascular complications from fillers is implementing safe techniques and knowledge of the vascular anatomy. While there is a paucity of data to support this, Dr. Weiner believes that cannula injections are less risky than needles for a vascular event. Larger cannulas, 25g or larger, are less likely to enter a vessel than a needle. While there have been cases of vascular occlusion with cannulas, to the author’s knowledge, none have been reported with 23g or larger. The smaller the cannula, the closer it becomes to looking like a needle, and therefore the advantages are less. (Please read Dr. Weiner’s blog about cannulas to understand their advantages.)

Techniques for optimizing safety during dermal filler administration:

  1. Know the major vascular structures and their landmarks
  2. Avoid areas you (the injector) are not comfortable with. Particularly the high risk areas: glabella, nose, periocular
  3. Consider using only reversible fillers if there is any concern regarding vascular occlusion or experience
  4. Use cannulas whenever feasible, preferably 25/23g or larger
  5. Avoid boluses, small linear threads are safer
  6. Constantly move tip of cannula/needle. If more filler is needed in a particular area, revisit the area with another pass.
  7. A NEGATIVE ASPIRATION DOESN’T EQUATE TO BEING EXTRAVASCULAR AND CAN GIVE A FALSE SENSE OF SAFETY
  8. Injection onto periosteum is safest but does not guarantee a vascular free injection
  9. Pressure on the supratrochlear vessels during glabellar or nasal injections might limit reflux of filler into the orbital vessels
  10. Retrograde injections are safer than anterograde injections
  11. Dermal injections should be relatively safe
  12. Avoid deep injections in the lips. Stay superficial to the muscles
  13. An injection that is perpendicular to a vessel is purported to be safer than one which is parallel because the time within the vessel should be less if it is entered
  14. Have on hand 6-8 vials of Hylenex
  15. Any unusual bruising, pain or visual change needs immediate evaluation

The bottom line is that complications can occur with dermal fillers, even during a routine procedure. Many measures can be taken to minimize the risks. Choosing an experienced injector will result in safer and better outcomes.

Dr. Steven F. Weiner is the #1 physician trainer for Galderma (Restylane, Silk, Lyft, Sculptra, Defyne, Refyne). He has been using cannulas since 2011 and is one of the most experience injectors in the US.



2/16/2018 3:03:52 AM

Nefertiti was recognized for her crisp jawline and smooth neck. Her bust is one of the most famous of the ancient Egyptian sculptures. A razor sharp jawline and well defined ascending ramus (or gonial angle) are hallmarks of beauty, both male and female. Jowling, submental fullness, blunting of the gonial angle, and an irregular jawline are all signs of aging.

While there are many commonalities between the sexes of what constitutes an attractive jawline, there are fundamental differences as well.

Males:

  • Broad/wide rami of mandible leading to a near vertical appearance on frontal projection
  • Approximately a 110-115 degree gonial angle (more acute than female)
  • Significant height of the body of the mandible
  • Wide defined, projected chin

Females:

  • V-shaped rami of mandible on frontal projection. A more masculine (vertical) ramus is also considered beautiful in some women (Such as Alessandra Ambrosio)
  • A more obtuse gonial angle of approximately 135 degrees
  • Shorter height along the body of the mandible
  • Pointed, less projected chin

There are considerable age related changes of the mandible.

  • Loss of bone along the body of mandible leading to loss of vertical height. This change is accelerated in an edentulous patient
  • Blunting of the gonial angle eventually leading to a curvilinear jawline
  • Narrowing of the male chin and widening of the female chin
  • Deepening of the gonial notch

The age related mandibular changes lead to loss of support of the soft tissue in the lower face – falling forward and downward. Jowling and submental fat is exaggerated. The upper neck skin shows more laxity as facial skin drops into the neck.

Correction of age related jawline changes with fillers- reJAWvenation

Dr. Weiner has perfected a correction using dermal fillers which he has coined “reJAWvenation”. It is based on restoring the age related loss of bone and leads to support of the lower face soft tissues. Filler is placed along the inferior border of the mandible as well as filling the gonial notch. The gonial angle is recreated. The lower aspect of the jowl is considered the new baseline and filling is made on either side to “camouflage” the jowl. Filler is also placed along the posterior aspect of the ascending ramus. The prejowl sulcus is filled, with emphasis to include the space beneath the inferior mandibular border. The chin must also be corrected to the male/female appropriate projection and shape.

reJAWvenation offers a quick (10-15 minute) correction of the age related changes to the jawline. Improvements in jowls, upper neck, jawline, and chin can be expected. There is minimal or no downtime. Even with facelifts, jawline volume is not typically addressed and needs to be corrected either during the procedure with fat grafting, or in the office, after healing, with fillers.

 



1/23/2018 3:27:24 AM

On October 12, 2017, Galderma was notified by the FDA that Restylane Silk was approved to be administered using blunt microcannulas. Galderma deserves a huge “high 5” for stepping out of the box in recognizing the improved patient outcomes and safety benefits of cannulas. No other dermal filler in the US has been approved for use with cannulas, it is a “First for Fillers”. Galderma is researching other areas for cannula use and expect approval in 2018 for another 1 or 2 indications.

What’s the big deal with cannulas?

The traditional method to administer dermal fillers is using a needle. Unfortunately, there are many side effects and risks using needles. These include:

  1. Bruising – sticking a needle into a highly vascular organ, skin, will lead to bruising a majority of the time. This is corroborated by the FDA studies for all the US approved fillers.
  2. Pain – needles require multiple entry points to deposit the filler. Pain fibers are most prevalent in the dermis.
  3. Vascular Occlusion Risk – when a blood vessel is cannulated with a needle and the filler is injected directly into the vessel, occlusion of the vessel occurs. The sequelae of such event can result in skin necrosis, eye injury, or even blindness.

Cannulas have a blunted, rounded tip which is less likely to injure blood vessels than a needle is. When the cannula brushes up against a vessel, it is deflected away, in distinction to a needle which will often pierce the vessel. When a vessel is traumatized, a bruise will occur.

To use cannulas, a small pilot hole using a needle is required. Unfortunately, completely eliminating needles is not possible. However, after that entry is performed, the cannula can be placed through the dermis and into the subcutaneous tissue or deeper fat compartments.  The areas below the skin surface are generally less innervated and are more comfortable to place filler.

The most important quality of cannulas is their safety. By design, they are much less likely to result in placement of filler within the lumen of a blood vessel. The rounded tip eludes lumens of blood vessels whereas needles don’t offer that protection. Although vascular occlusion is possible with cannulas, it is much less likely when compared to the risks associated with needles.

Dr. Weiner has been an advocate of injecting dermal fillers with cannulas for the past 6 years, since 2012. He has become one of the most experienced cannula users in the US. He has been chosen by Galderma to use his cannula experience to “Train the Trainers” in the use of cannulas for Restylane Silk in the lips.



12/16/2017 11:34:34 PM

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



12/10/2017 2:48:52 PM

“A picture is worth a thousand words”. It’s true, seeing a great before and after speaks volumes for a certain physician’s or practitioner’s abilities. Unfortunately, there are some deceptive practices that can trick the eyes into believing results are better than they are really are.  Instagram is a showcase for the aesthetic industry, but there is no oversight as to the claims made on the photos displayed. The bullet points below will help one to develop a critical eye to discern the truth from the “fictional results”.

  1. Lightening must be the same in both pictures. A common misleading practice is to have a dark before picture and a light after picture. In the lighter picture, wrinkles and shadows are going to be less, and fool the observing into thinking these were related to the procedure.
  2. Angle of the neck/head must be the same in both pictures. Take a look at the nose and jaw to see if the head is in the exact same position. If the head is tilted more upward in the after picture, the neck will appear to have less fullness, less wrinkles, and be firmer. This is particularly popular in the Kybella before and after photos.
  3. The expression must be the same in both pictures. If a patients is partially smiling in the before and not in the after, the wrinkles around the mouth and cheek will appear falsely improved.
  4. Sculptra pictures should have at least a 3-6 month interval. Sculptra is always mixed with water or saline for reconstitution. The immediate results after injection reflect merely the effects of the water/saline and not that of Sculptra. The collagen stimulation from Sculptra will take at least 3 months to appreciate, with 6-9 months being even a better gauge of results.
  5. Using company photos or other physician’s photos without noting this or giving the appropriate credit on their websites or posts is also a common practice.
  6. If make-up is used, it must be similar in both photos. Too often the before has none and the after has make-up.

Perfect before and after photos are very challenging. Even when results are extraordinaire, there are often difficulties trying to capture these changes with the camera. However, purposely trying to “enhance” photos with the practices above must be pointed out to the practitioners.

 



11/13/2017 11:58:51 PM

In surgery, sterile technique is “the law”. Any break in sterility places the patient at risk for a potentially life threatening infection. It is the duty for the surgeon(s), scrub tech, and circulating nurse to self report or call out any suspected or potential contamination risk. Immediate actions are taken to remedy the situation and to limit the risk to patient.

Why should dermal fillers be treated as anything differently? They shouldn’t! Fillers are semipermanent or permanent implants, and they must be administered in aseptic technique. The majority of injectors are not trained as surgeons and therefore don’t fully comprehend what sterile technique entails. Granulomas, one of the more serious complications from fillers, have now been traced to biofilms. Biofilms are latent bacteria that somehow get activated and present as infection or granulomas, months to years after the initial injection. Most often biofilms are deposited in the tissues during the initial injection procedure. Clearing infections or granulomas takes weeks or months to clear and often entails antibiotics, steroids, 5 FU, and hyaluronidase (if a hyaluronic acid was used).

The following guidelines should serve as a reference for physicians and nurses to minimize infectious complications during dermal filler injections.

  1. The patient should clean their face thoroughly with soap and water in the office. All make-up must be removed.
  2. Never inject someone with a current/ongoing infection. Even if the infection is not in the area of the dermal filler, bacteria can seed the filler from distant areas through the bloodstream (bactermia).
  3. If a patient is in the process of getting dental work or even dental cleanings, hold off on injections until after the work has been completed. Bactermia is well documented during dental cleanings. It is recommended to wait at least 2 weeks after fillers to get dental cleanings. The areas of filler placement will initially have increased blood flow (hyperemia) so it is best to wait until this settles down.
  4. Skin should be prepped for injection with chlorhexidine, with Hibiclens being the preferred form by the author. Although isopropyl alcohol (70%) is effective in killing bacteria and fungus, it is only effective for seconds and becomes ineffective as soon as it evaporates. Hibiclens kills germs on contact and will give persistent bactericidal effects for at least 6 hours, and up to 24 hours. It will bond with the skin even after washing to give continued killing effects. Isopropyl alcohol doesn’t give this lasting bactericidal effect, so anytime after the initial cleaning that an unsterile glove touches the skin, that area is now contaminated. (Hibiclens must be kept out of the eyes because it can burn the cornea). Technicare is also a great antiseptic but the author doesn’t have experience with it. Too many patients are allergic to Betadine for it to be used routinely.
  5. Do not use tap water when applying Hibiclens or to clean the face after completion of the injections. There are several bacteria, fungi, as well as mycobacterium in water which can seep through the injection ports and cause infection.
  6. If the filler is prepared by mixing lidocaine or saline, this must be done in a sterile fashion. The female/female connector used to connect the 2 syringes together must not be reused. It can only be used for the current patient and cannot be sterilized for use on other patients. The tops of all the solutions used must be wiped with an alcohol wipe. Routine use of blending fillers opens up more avenues for filler contamination and must be done with the strictest of sterile technique. If any of the solution vials becomes unsterile, all future filler patients using that vial will become infected.
  7. Blunt tip cannulas can be used for multiple injection sites ON THE SAME PATIENT and are not intended to be used for multiple patients. When changing the cannulas between syringes, they should be recapped first. It is not sterile technique to lay the cannula on an unsterile tray or even a sterile drape when uncapped. After a syringe of filler is removed from its sterile packaging, the areas touched with the exam gloves become “contaminated”. Therefore, the sterile drape is not a sterile field anymore, once the syringes is placed on it. Best practice is to cap the syringe every time it is laid down.
  8. Blunt cannulas are much longer than needles and must be kept sterile throughout their entire length. The cannula is contaminated if anywhere along its length it touches non sterilized skin, gloves, or hair.
  9. It is never appropriate to touch a needle or cannula with unsterile gloves. The needle/cannula are now contaminated and must be exchanged.
  10. The introducing needle for the pilot hole with cannula use must be recapped as well to maintain sterility.
  11. Unless the gauze used during the procedure is specifically labeled as sterile, it is not, and introduces another route of contamination. Gauze that comes in sealed pull away packs and labeled as sterile is best to use. The author will take unsterile gauze, place in autoclave packs, and place in the autoclave to obtain sterility.
  12. Frequent “re-sterilization” of the areas being treated with Hibiclens soaked gauze is done by the author.
  13. If ice or devices for vibration are used to control discomfort, these should be cleansed with Hibiclens prior to applying to the skin. In addition, the areas where these were applied should be “re-sterilized” prior to injections.
  14. When the procedure is complete, sterile water or saline on sterile gauze should be used to clean the patient. Again, if tap water is used, this can seep through the injection ports and lead to infection. Also, when soaking the gauze, best practice is to pour the water/saline over the sink onto the sterile gauze so as to keep the remaining fluid in the container sterile. By tipping the water/saline onto gauze that is covering the top, there is risk of contamination going back into the container.
  15. Make-up should not be applied to the skin until the morning. At this point, the injection ports have all healed and there is no risk of contamination.
  16. Dental procedures, even cleanings, should be postponed for at least 2 weeks.

Although the details above are fairly lengthy, any break from any step will lead to a possible source of granuloma or infection in the future. Strict sterile technique will lead to better outcomes and happier patients,



10/2/2017 12:49:38 AM

A couple years ago, I wrote a blog that stated deep injections along the periostium using Sculptra were the best way to enhance temples suffering from volume loss. I would like to update everyone to a newer technique I have perfected that gives better results.

Although the Sculptra temple injections are safe and long lasting, there were deficiencies:

  1. Multiple treatments were required – 3 or more
  2. Results take weeks or months to occur
  3. Final results still showed volume loss in the temporal fusion line and supraorbital area
  4. Significant volumes of Sculptra were required
  5. Needle injections inherently lead to more bruising than cannulas

The temporal fossae is a very large space and when Sculptra is injected in this area, there is tremendous spread of the product due to its watery consistency.  In addition, the deep temporal fascia is a thick and unyielding tissue plane that resists lateral movement from filler placed deeply.

My current preference for volumizing the temples uses large (23g) cannulas and a diluted HA (Refyne) dermal filler. I use large cannulas because they are safer than the smaller cannulas and needles for preventing vascular occlusion. I have found that the larger cannulas navigate the numerous veins in the temples well with minimal discomfort.  My entry point is the zygomatic arch, about 1 cm posterior to the brow. The plane of injection is between the superficial temporal fascia and the deep temporal fascia. This is the exact area where the temporal fat pad is situated and where fat loss occurs.  Surrounding areas such as the superior orbital rim, supraorbital area, forehead, and hairline can all be injected from the temporal approach. By diluting the Restylane Refyne with 1cc of saline and 1cc of lidocaine 1%, the thinner product is able to distribute very evenly throughout the plane of injection. Refyne’s high tissue integration and low swelling properties makes this the optimal filler for this area. I have found that a total of 1-2 syringes of the filler is needed to achieve correction in most patients. Massaging at the time of injection and periodically afterwards by the patient will give the smoothest results. A follow up in 3 weeks is typically made to make final touch ups if needed.

Techniques must constantly be re-evaluated and refined to achieve the optimal and safest results for our patients.

 



9/24/2017 7:47:38 PM

Aesthetic physicians are constantly striving to find the best procedure/device to turn back time. This time, it is actually a procedure which has been used for decades, but with some modifications. Fat grafting is a procedure that harvests fat from one part of the body and then injects the fat into another area. It has been used to volumize the aging face, hands, and even breasts. Benefits of fat grafting in repairing slowing healing wounds and radiated tissue have shown there are additional qualities to this procedure other than just volume. It turns out that fat contains stem cells and growth factors, more than any other tissue in the body, even more than bone marrow. The component of the fat that contains the stem cells and growth factors is called the “stromal vascular fraction”, also know as SVF.

When digging down into the research, an interesting finding has been discovered. It turns out that most of the fat cells injected don’t actually survive. What actually happens is that the stems cells (Adipose Derived Stem Cells – ADSC) injected along with the fat cells (SVF) leads to new fat cell production.

So here’s the new modification of the procedure. There is new a way to separate the SVF from the fat, without affecting the viability of the stem cells. This process creates the so called Nanofat, a highly concentrated solution of stem cells and growth factors.

It is a process of using filters and screens which takes less than 15 minutes to perform. It turns out that fat cells make up about 80% of the volume of the fat extracted during the harvest. The filtration system leads to destruction of the fat cells (which don’t live anyways) and leads to a much thinner solution which can be injected using smaller cannulas or needles than typical fat grafting procedures.

It turns out that Nanofat actually contains little to no viable fat but is the popular term for the SVF derived from fat. To even further “energize” the Nanofat injections, PRP or PRF is mixed with the solution. This process gives additional growth factors which benefit in the fat production and overall repair and rejuvenation of the areas treated.

Nanofat injections are often combined with fat grafting which is modified from the classical method. It has been found that the inconsistent “take” and lumpiness of fat grafting is related to large size and nonuniformity of the fat harvested. To overcome these hurdles, the harvesting process is now done with smaller cannulas and the fat is pushed thru filters to make uniformly smaller sized fat globules.

Nanofat is useful to treat:

  1. Crepey skin around the eyes
  2. Superficial lines and wrinkles
  3. Smoker’s lip lines
  4. Thin, atrophied skin
  5. Severely sun damaged skin (in combination with other procedures)

The use of Nanofat, with or without fat grafting, requires a minor liposuction procedure to harvest the cells. This is done completely under local anesthesia. Only syringes are used as suction and the cannulas used are much smaller than typical liposuction. There will be some downtime of swelling, bruising, and redness, that typically lasts a few days or up to a week (longer in a minority of patients). Full results require about 9 months to fully appreciate – the time required for new fat and skin cells to be generated.

We now have a completely natural way to rejuvenate and reverse the affects of aging, using stem cells derived from fat cells – Nanofat. The process of isolation of the stem cells and growth factors from fat has become an extremely viable option with a 90 minute procedure.



7/3/2017 1:42:19 AM

The adoption of dermal fillers for age related volume replacement has contributed to the surge in aesthetic patients. As patients become more savvy, it becomes obvious that filler outcomes are dependent primarily on the provider and not the brand of the filler injected. Somewhere between 80-90% of the fillers used are based on Hyaluronic Acid, a naturally occurring substance found throughout the skin, and joints. (It is an interesting side note that the structure of HA is similar throughout all species.) One of the attractive qualities of HA is that there is an “antidote”, an enzyme called hyaluronidase, which can dissolve HA based dermal fillers.

There are several versions of hyaluronidase available in the US. There are animal based products such as Vitrase (ovine based), Hydase (bovine), and Amphadase (bovine). The one product, Hylenex, is actually a recombinant form of the human hyaluronidase. There is some risk of allergic reaction to the animal based products but not Hylenex (author’s preferred choice). The intended use of hyaluronidase is to allow for increased tissue permeability, thereby allowing for greater dispersion and delivery of products injected. It is also used when hyperosmolar fluids extravasate into the skin and in improving uptake of radiopaque solutions in the bladder. The primary reason it is used in aesthetics is to dissolve HA filler.

The reasons to dissolve HA filler are:

  1. Poorly placed filler giving an aesthetically poor result
  2. Where too much filler was placed
  3. Filler that is infected
  4. Filler is forming a granuloma
  5. Filler is causing ischemia/vascular occlusion
  6. Filler is causing visual changes or blindness

The are more and more fillers being introduced to the market each year. Each one has it’s own characteristics and nuances when injecting. There are also, many new injectors entering the industry daily. It is fair to say that the number of poor outcomes and complications is inevitably going to rise. Unfortunately, trainings are not being done for the indications and administration of hyaluronidase. It is beyond comprehension that there are many offices, I dare say, a majority, who either don’t normally have any or adequate doses of hyaluronidase.

It is absolutely imperative that a facility that injects HA fillers stock at least 1000 units of hyaluronidase. Doses of 400 units or more need to be injected in areas of vascular occlusion immediately to achieve optimal outcomes. If no response, additional doses need to be injected. If an ophthalmologic complication occurs, at least 1000 units needs to be injected immediately to have any chance for recovery of vision. Even with doses in the thousands of units, there should be no concern regarding loss of naturally occurring hyaluronic acid as it will replaced by the body’s normal regenerative process over 24-48 hours. 

Unfortunately, the majority of providers have little or no experience with hyaluronidase and/or have none available in their facilities. It is beyond comprehension the lack of preparedness for not only reversing poor outcomes, but in resolving medical emergencies. The industry must rise up to educate about complication identification and treatment protocols. Poor outcomes and complications affect the entire aesthetics field and not just the individuals involved.



6/21/2017 12:23:48 AM

The nonsurgical aesthetic industry has finally hit an important milestone. Using a combination of techniques, cosmetic physicians are now able to halt, and even reverse, the age-related changes which occur to one’s face. In the past, technologies would allow for turning back time for a few years but eventually, the inevitable and undeniable signs of aging would occur. As lasers, radiofrequency (RF), filler and neuromodulator techniques have improved, the aging face is a thing of the past. The concept of “age freezing”, keeping ones looks for a decade or more, is not merely a dream, but reality. More importantly, this all can be done without surgery!

Not everyone is a candidate for “Age Freezing” unfortunately. The stipulations are:

  1. Must be a nonsmoker – There are several significant skin and health issues associated with smoker which can’t be overcome. Many procedures require healing and collagen stimulation which are inhibited by smoking.
  2. Free of chronic debilitating disease – There are tolls long term diseases take on the body which lead to premature aging, cellular changes.
  3. Stable weight – As Katherine Deneuve once stated, at the age of 40, you must decide between your ass or your face. If you lose too much weight, fat is lost from your face. In most instances, this can be overcome but not always. However, in patients with significant weight gains, there can be some difficulties maintaining the same look one had in the years prior.
  4. Alcohol consumption in moderation – Alcohol can take a toll on the body in the long run when taken in excess. 1-2 drinks per day is the recommended maximum intake that the author recommends.
  5. Healthy lifestyle and diet – Although this topic overlaps some of the previously mentioned necessities, a good exercise regime is also required. The benefits of exercise on weight, hormones, circulation all benefit the facial appearance. Obviously, a well-rounded diet full of antioxidants, vitamins, and nutrients is beneficial too. There is research to support telomere lengthening with these measures as well.

The requisite procedures for “Age Freezing” are:

  1. Neurotoxins on a regular basis. Relaxing the hyperdynamic muscles of the face with either Dysport or Botox needs to be performed at least 3 times per year. The regularity is needed to keep the muscles weak and prohibiting them from regaining strength.
  2. Dermal Fillers for lost volume. Fillers are the epicenter of the whole “Age Freezing” concept. Beginning in the mid 30’s, at least a cc of volume is lost per year. This is the result of fat, bone, and muscle loss. Replacing and keeping up with this process is tantamount to looking young. Large volumes are best replaced with using Sculptra, a collagen stimulating filler. It is best to recreate the foundation with Sculptra. Superficial fine tuning is best performed with a hyaluronic acid filler, such as Restylane. New techniques using blunt cannulas permitted safer, less downtime procedures. A comprehensive understanding of the aging process has enlightened our specialty as to what needs to be corrected for accomplishing age reversal.
  3. Skin Tightening to reverse gravity. The constant downward pull due to gravity leads to skin laxity, above and beyond what is attributable to volume loss. Devices that heat up the dermis will stimulate collagen and tissue contraction. Devices vary in their ability to tighten, often with a tradeoff of more downtime/discomfort/risk for more results. Ablative lasers, CO2 and Erbium, will give the most tightening for lasers. Radiofrequency can also be used, with the microneedling RF, such as Infini, giving the best results. A new procedure called JPlasma, looks like it may have promise in significant tightening, but does have about 14 days of downtime and a month of redness.
  4. Skin Resurfacing to improve pigmentation, fine lines, and thicken the dermis. The aging process, primarily due to sun exposure, causes skin to thin with loss of collagen and elastin. Dyspigmentation, pigmentation problems, occurs as well. Renewing the surface of the skin can be accomplished using lasers, such as the Fraxel Dual, or chemical peels. Microneedling can thicken the skin by producing small injuries in the dermis with very little downtime or risks. There may be benefit to adding PRP, platelet rich plasma, to the skin, but the jury is still out.
  5. Skin Care is essential to achieve the optimal results from any of the above mention procedures as well as to improve one’s skin health. Retin A or Retinol should be a staple in one’s nightly regime. These products stimulate skin turnover, reversal of pigmentation problems, better hydration with hyaluronic acid stimulation, and collagen production. Blemishes/Acne breakouts are improved with these products as well.
  6. Oral Supplements are key to good, healthy skin. Oxidants are the source of disease, cancer, aging, and skin damage. To neutralize the oxidative stress, strong anti-oxidant supplement(s) are necessary. Examples include: superoxide dismutase, fish oils, resveratrol, Polypodium leucotomos, turmeric, and glutathione. In addition, the antiaging benefits of Metformin are hard to dismiss with the current research published. Lengthening one’s telomeres with TA65 is probably beneficial as well.

One must understand that the “Age Freezing” concept is a process. It is a lifestyle, a choice. It is not a “one and done” procedure. It consists of regular visits to an aesthetic physician. There are big steps and little steps along the way. The author has dozens of “Age Freezing” patients whom look younger and better, 10 or more years after initiating treatments. “Age Freezing” will eliminated the need for future cosmetic surgery.



6/17/2017 10:38:51 PM

It’s been touted for years by the aesthetic physicians – “Prejuvenation” – starting maintenance treatments in one’s late teens or early twenties.  The Kardashians have popularized these minor cosmetic tweaks to stay youthful and refreshed with visits to their Beverly Hills physician, documented regularly on “Keeping Up with the Kardashians”. There is increasing pressure to get that perfect selfie for Instagram or to look cool and attractive on a “Snap”. Unfortunately filters don’t work well with videos unless you want to look like a cute puppy. Doctors are in agreement (for any disease process) that it is much easier to treat problems in their early stages than to reverse them after they have spiraled out of control. Small preventative treatments early on, can maintain and even enhance one’s looks for many years and avoid invasive surgical procedures in the future.  The question is, which procedures should be considered for Prejuevenation?

Neuromodulators: These wrinkle improving injections take less than 5 minutes and have no downtime. Millions of these procedures are done each year and it is the most popular cosmetic procedure performed worldwide. Most often these are used in the younger population in the frown lines (glabella), forehead lines, and crows feet. Treating these areas before the lines set in at rest, known as “etched in” lines, is one of the fundamental concepts of Prejuvenation. (Suggestions: Dysport, Botox)

Dermal Fillers: Dermal fillers made from hyaluronic acid (HA) are used to improve the minor volume loss which occurs with age. In the more athletic patients, fat loss can be appreciated in the face as well as throughout the body. Supple enhancements can be added to the mid cheek and around the eye to stave off this premature volume loss. HA fillers are also used to plump up the lips to create a youthful appearance. (Suggestions: Restylane Refyne, Restylane L, Restylane Lyft, Sculptra)

Chemical Peels: To keep the skin in top notch shape and to reverse early sun damage, chemical peels can exfoliate the superficial layers of skin. This renews the texture and pigmentation and leaves a youthful and glowing quality to the skin. (Suggestions: Illuminize, Vitalize, ZO 3 Step Peel)

Skin care: Great skin care is the basis for good looking skin. Most would agree that some type of Retin A or Retinol is essential for maintaining youthful skin. These products lead to increased turnover of the skin cells, improve dyspigmentation (pigmentation problems), thicken the skin, and create a more hydrated skin. Sun protection with an SPF should be part of one’s daily regime. It is also highly recommended to apply growth factors to the skin to reverse the aging process. (Suggestions: ZO Skin Health, Lifeline Stem Cell Skincare)

Prejuvenation is a trend that is here to stay. Preventative maintenance will prolong the need for more aggressive corrections in the later years. With short, no downtime procedures such as neuromodulators, chemical peels, fillers, and a good skin care regime, youthful, natural appearances will persist for years. Stay ahead of the curve with Prejuvenation.



6/16/2017 1:48:18 AM

 

Acne affects millions of people in the US, and is the most common reason to seek medical attention from a Dermatologist. Billions of dollars are spent on medications to control the disease, both over the counter and prescription. Medications have potential side effects, and compliance is difficult. Even with aggressive medical therapy, acne can be difficult to control, which leads to frustration by patients, parents, and physicians. With prolonged cases of acne, scarring can set in, creating an even more difficult problem to treat.

It’s the early teen years, as one is experiencing puberty, when acne usually starts.  This period coincides with high school, selfies, and an interest in dating. Acne can negatively impact social interactions and lead to depression, moodiness, negative self-worth, and isolation. Controlling acne is a top priority for large number of teenagers in the US.

A cascade of events leads to acne:

  1. A trigger: hormonal, emotional, stress, metabolic
  2. Increased sebum (oil) production from sebaceous glands
  3. Plugging of the follicles by the sebum
  4. Infection of the sebum by bacteria
  5. Inflammation related to the infection/immune response

Treating acne with lasers is not a new concept, but the Aerolase has made the process more effective and safer. Even the wavelength, 1064nm YAG laser, is not novel to the Aerolase. However, having a pulse width of 650 microseconds is unique. The Aerolase sits in the middle of the prior lasers used to treat acne, the Q Switched (nanosecond) and the Excel V/VBeam (millisecond). It has been shown that this pulse width is better tolerated than faster and slower lasers, and therefore more pulses and even stacking can occur. Deeper and more broadly-based heating occurs with the Aerolase. With the increased heating of the acne, the laser becomes more effective in its eradication. The 1064 wavelength is safe for all skin types, but settings are reduced for the darker skin patients. The Aerolase laser treats acne by:

  1. Heating up and shrinking the sebaceous glands leading to lower sebum output
  2. Killing the acne bacteria
  3. Reducing the redness associated with the acne
  4. Improving early scarring
  5. Reducing the inflammatory component of acne

Typically, a series of treatments are needed, 4-6, about a week or two apart. Touch ups are needed every 1-3 months. Flairs should be treated acutely, so they are controlled quickly. Continues use of topical therapy is usually recommended, such as Retin A and benzyl peroxide. The Aerolase gives patients a unique, no downtime, near painless 10-minute procedure to help control even the most difficult cystic acne.

“Get rid of that Instagram filter and show your true selfie.”



5/28/2017 2:24:27 PM

Coolsculpting’s original FDA approval was in 2009 and it was initially cleared to cool skin prior to dermal procedures. It was later in 2010 that the FDA approved Coolsculpting for fat reduction in the flanks (love handles). Over the next several years, the procedure has been approved for abdomen, thighs – both inner and outer with various sized handpieces to treat every body type.

What’s new is that there are 2 new indications for Coolsculpting treatment. The submental fat (double chin) can now be treated with the Cool Mini handpiece. Depending on the needs of the patient, one or two applications are needed. Treatment times are 45 minutes. There is no downtime as is customary with all Coolsculpting procedures. A 2nd treatment is needed in some patients who need larger corrections. Another exciting area of recently approved treatment is the underarm area. This is where the new Cool Petite handpiece is used. Loose skin is not going to improve but that annoying “bat wing” can be reduced with these treatments.

In 2016, there was a significant change to the handpieces used for treatment called the CoolAdvantage Handpieces. (Not all practices have upgraded to these, so patients must inquire). The difference is that these handpieces are more shallow – the amount of suction witl therefore be less. The cooling plate is continuous rather than just the sides. The area treated is now more uniformly cooled than with the prior handpieces. These changes result in:

  • More comfortable treatments
  • Treatment times of 35 minutes vs the usual 60 minutes
  • Faster onset of results – as little as 3 weeks
  • Less bruising and post procedure pain

Soon after Coolsculpting’s approval it had been noted that manual massage post treatment led to improved results. About a couple years ago it was found that using the Zimmer Z Wave in place of the massage yielded even better results. It was found that adding the Z Wave increased the treatment efficacy by 68-100%. The Z Wave uses Acoustic Pulsed Technology, which sends shock waves through the skin and fat. It is a painless 5-10 minute procedure. These shock waves further injure the fat cells leading to a better result. After the Coolsculpting treatment, there are fat cells which are killed, some unaffected, and some which are “on the fence” as to whether they will survive or die. The Z Wave pushes some of these “undecided” cells over the brink. Z Wave has also been shown to lead to less post procedure discomfort.

“If one is good, two is better”. In some practices, a second Coolsculpting machine has been purchased. This allows for “DualSculpting”, treating 2 areas simultaneously. Treatment times are then cut in half using this technique.

Comparing the DualSculpting to  treatments 1 year ago, two areas can now be treated in about one quarter of the time when adding the benefits of the CoolAdvantage Handpieces.

The Aesthetic Clinique has been one of the pioneers in Coolsculpting treatments. Its first machine was obtained in 2009, being one of the first 25 in the country, even before the formal FDA approval for fat reduction. All the latest handpieces are available including the CoolAdvantage, Cool Mini, and Cool Petite. The Zimmer Z Wave is a complementary service added to all Coolsculpting treatments. A second machine has just been purchased, so DualSculpting is now available at The Aesthetic Clinique.

Recent advances have made Coolsculpting significantly faster, more comfortable, and more effective. It is a great noninvasive procedure for reducing unwanted fat without downtime.



3/14/2017 9:00:28 PM

(Dr. Weiner is one of the most experienced users of Restylane Refyne and Restylane Defyne in the US and has trained multiple physicians on his injection techniques of these new products.)

IMG_6825

Restylane Defyne Treatment Radial Cheek Lines – Dr. Steven F Weiner

Late 2016, two new dermal fillers, Restylane Refyne and Restylane Defyne were FDA approved. Although new to the US, these fillers had approval in Europe in 2010  and in Canada in 2015 under the name Emervel. The announcement flew mostly under the radar and it wasn’t until early 2017 that Galderma officially launched the new fillers. Although these fillers are similar in composition, hyaluronic acid (HA), to many of the other fillers on the market, it is the technology behind them that set them apart from the rest.

Restylane Refyne and Defyne are made with XpresHAn technology which adds flexibility to the fillers – “think honey” – and makes them perfect for treating areas of expression. (Other Restylane fillers are based on NASHA technology, and are particulate in nature – “think sugar”.) Additionally, Refyne/Defyne have high crosslinking that lends to their ability to stretch and recoil. Refyne has less links, so it can stretch more, while Defyne is more tightly bound.

The clinical outcomes of using Refyne and Defyne are unique and directly related to their manufacturing process. With placement in the dermis using small aliquots (a different technique than other fillers) in areas of high muscle movement (expression), the filler will support the skin and soft tissue in unparalleled ways. In fact, muscle strain around the mouth was tested before and after Refyne/Defyne placement and was shown to revert a 55 year old’s profile to one similar to a 30 year old on average. The hyperactivity of the muscles was “constrained” by the filler, just as Botox or Dysport does in the glabella and crows feet. The previously difficult to treat radial cheeks lines (smile lines) can now be improved significantly with the new Restylane Refyne/Defyne fillers. Other fillers used to treat this area are more apparent and obvious due to their lacking the XpresHAn technology, and don’t look as natural with movements. Adding bulk/volume to the lower face is usually not desired because beautiful and youthful faces are V or heart shaped. The unique placement of Refyne/Defyne in the dermis does not add fullness in the lower face during corrections of the marionette lines, prejowl sulcus, and smile lines in Dr. Weiner’s experience.

Cohesiveness is the ability of a filler to “stick to itself” and integrate with the surrounding tissues. Both Refyne and Defyne have a high cohesivity. This equates to more blending of the filler with the tissues, and a more natural appearance. In clinical use, these new fillers can be injected into the mid/deep dermis (a dermal filler actually being injected in the dermis!) and still go unnoticed, without nodules or lumps.

One final highlight of Refyne/Defyne is their low degree of swelling associated with injections. This is beneficial for areas such as lips and tear troughs, where swelling can lead to social downtime, precluding some clients from doing these procedures. When comparing all the HA fillers available in the US, it’s been Dr. Weiner’s experience that Refyne/Defyne have the least amount of swelling.

Restylane Refyne and Defyne open up a new treatment paradigm for the perioral smile lines (radial cheek lines) where previous corrections were usually suboptimal.  This area is often overlooked or discouraged, but is a frequent concern for a majority of dermal filler clients. The satisfaction rate with these corrections have been extremely high in Dr. Weiner’s experience. With the additional benefits of high conhesiveness and low swelling, Restylane Refyne and Defyne are a great addition to the filler armamentarium of the advanced injector.

File Mar 14, 10 13 31 PM



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Aesthetic Clinique
2050 W. County Highway 30A, Suite 114 Santa Rosa Beach, FL 32459
Phone: (850) 622-1214 URL of Map