Fundamentally, aesthetic physicians can look to two device types for skin-tightening offerings: radiofrequency (RF) and ultrasound (US). Because of its versatility and efficacy, RF technology holds many indications, including its most common: non-ablative tissue tightening. Ahead, Mary Lupo, MD, a board-certified dermatologist who practices in New Orleans, LA, discusses how she uses RF technology for patients looking to improve skin laxity and reduce wrinkles without surgery.

What is your experience with skintightening technologies?

Dr. Lupo has held demonstrations with Thermage (RF; Solta Medical), Exilis (RF; BTL Aesthetics), Titan (pulsed light; Cutera), and Ultherapy (ultrasound; Ulthera), but she has “the most experience with the Exilis family of products,” she says.

How does the Exilis technology work?

Exilis Elite uses Impedance Intelligence Technology, which helps control the energy flow from the device. “In aesthetic treatments, we have to balance using high energy levels without compromising patient comfort,” Dr. Lupo explains. The Exilis Elite controls and automatically eliminates energy peaks, which ensures no sudden surge in energy and provides optimal skin tightening. Exilis also offers body contouring.

The Exilis uses a proprietary cooling system that provides greater control for accurate tissue heating, according to Dr. Lupo. “We use cooler surface temperatures to help the radiofrequency energy go deeper,” she says. “In this way, we can target the tissue we want to either compromise fat or tighten skin all over the body.”

Which patients do you find are most interested?

With a skewed patient population, and since she has a non-surgical practice, Dr. Lupo is usually greeted with the patient who wants a non-surgical option. “Typically, they ask for Exilis by name. I always set realistic expectations and tell patients, ‘If face lifts are a home run, Exilis is a base hit,'” she says. Patients should be aware of expected results going in to these procedures. “It works best for those patients who I call ‘not too far gone,'” says Dr. Lupo. She finds there is consistent improvement after the procedure that 80 percent of the patients find very satisfying.

How does RF fit your practice?

Based on a range of zero (lowest) to 10 (highest), Dr. Lupo will not add to her practice offerings if a device is at the cost of a “6” and gives results of a “3” or “4.” “Because the Exilis Elite lacks expensive disposables, I can offer reasonably priced results to patients,” she says. Dr. Lupo has well-trained technicians and holds updated in-services as the technique is improved. “We grow with the product. Beyond looking at the technology, the acquisition cost, and the cost of disposables, I always look at the company. We wanted great training and needed updates as protocols evolved. BTL provides excellent service after the sale, so we have a continuing relationship that is valuable to our success,” she says.

Before and after photos of using Exilis Elite for skin tightening (top) and neck rejuvenation (bottom).

What is the number and length of treatments for the Exilis?

Dr. Lupo asks patients to commit to four treatments and explains it is not a one-time procedure. Optimally, she likes patients to return at two-week intervals, which she finds is a manageable protocol for most. She is sure to take photos at baseline and then again two to four weeks after the fourth treatment to evaluate the results.

Typical treatments take 20 to 30 minutes each. There is no downtime, but some patients may seem somewhat pink for a short time after, Dr. Lupo explains. “There is usually an immediate tissue tightening in many patients, and the results will improve over time,” she says.

How do patients respond to their results?

Certainly, there are individual responses, Dr. Lupo says. “I use the example of 10 patients with a headache. If they all took acetaminophen, some would still have a headache. Maybe some respond better to ibuprofen, or maybe some need a prescription for severe cases.” Since her office is electronic, Dr. Lupo will pull up patients' “before” photos and same-day “after” photos to review results. If they are satisfied, then she recommends continuing treatments. If not, then this treatment is not for them. “There's no guarantee, but it is a non-surgical treatment that is profoundly safe and reasonably effective,” she says. “The number-one comment I hear from patients is that people ask them if they have lost weight.” When patients gain weight, they lose definition in their jawlines, Dr. Lupo explains. Tightening the neck with Exilis provides a “shadowing of the neck and illusion of weight loss because the jawline is more defined,” she says.

What is the demand? Are you marketing Exilis Elite?

Dr. Lupo is not advertising Exilis Elite, but it is featured on her website, email blasts, and monthly e-newsletters to existing patients, though not emphasized more than other technologies. “Usually, patients will do one area and then want to do another, or tell their friends about it, so Exilis is self-perpetuating,” she says.

From a business standpoint, Dr. Lupo finds that the product's versatility is ideal, since it works effectively on all skin types and has no disposables. “It won't replace surgery, but patients will see some very nice improvement. And staff find it easy to use, so it's a win/win for the practice.”