A Tight Fit: Can Non-Invasive Tissue Tightening Devices Fill a Niche in Your Practice?

Pelleve: A Patient-Friendly Option for Non-invasive Tightening

Amy Forman Taub, MD

What is Pelleve and how does it fit within your practice?

As the field of tissue tightening devices for use on the face and neck has increased, our practice has incorporated many technologies, each of which may provide a distinct benefit in certain settings. However, Pelleve (Ellman International) has emerged as one of our most popular offerings, as it is a generally painless but effective intervention for non-invasive tissue tightening in the face and neck area.

Pelleve is a monopolar radiofrequency device that delivers thermal energy to the dermis without damaging the epidermis. The thermal energy induces collagen contraction for a tightening effect, leading to improvement in the appearance of the skin. It is appropriate for use on all skin types, and is suitable for many presentations of skin laxity. For certain patients with excessive laxity or very thick skin, a more invasive laser procedure may be indicated as an alternative to non-invasive tightening. Additionally, it must be noted that radiofrequency treatment is contraindicated for any patient with embedded metal, such as a device in the chest or abdomen or a plate in the head. For such patients in our practice, we would usually use Titan (infrared device, Cutera).

Pelleve is ideal for the patient who cannot tolerate pain or prefers not to tolerate pain. Our protocol is to provide one treatment per month for three months with a single repeat treatment provided at about six- to eight-month intervals. In our practice, aestheticians provide Pelleve treatments, whereas the PA or physician staff usually administers other tightening devices.

What is treatment like for patients and what can they expect?

Patients will typically see results immediately following their first treatment, which will generally diminish by about four weeks—when they are due for a repeat. Optimal results are seen about three months after the third treatment. Especially for patients who are receiving other minimally invasive procedures, such as filler or toxins, the notion of regular follow-ups is familiar and well accepted.

Some patients, however, will prefer not to undergo multiple treatments. These individuals are often treated with Thermage in our practice. Such patients typically present for retreatments every 18 months to two years. Thermage, which is associated with more pain than Pelleve, may be somewhat more effective for a patient with very thick skin or more significant laxity. In our practice, however, the two devices tend to be used for similar patient presentations, with similar results. Ultimate choice of one device over the other often depends on patient preference. We present all the treatment options to each patient, outlining the strengths and weaknesses, and guiding them to the decision that is best for them.

As a practitioner who has had Thermage since its introduction, I think it is important for other clinicians to understand that adding Pelleve has expanded—not redistributed— my base for minimally-invasive tissue tightening. Patients who had not elected to undergo Thermage treatment have opted for Pelleve. As with other aesthetic indications, each device has its unique benefits and drawbacks. Incorporating multiple devices for non-invasive tissue tightening can allow a practice to optimize outcomes for a wider body of patients.

Updates Continue to Expand the Appeal of Thermage

Michael J. Kaminer, MD

How does Thermage provide its tightening effects and how does it differ from some of the other approaches on the market?

Thermage has proprietary radiofrequency technology that uniformly heats skin. In my opinion, this allows Thermage to more predictably and completely heat collagen in the target zone, resulting in uniform skin tightening. The current generation of Thermage with the Total Tip has evolved significantly from the technology from the early 21st century, improving on efficacy that other companies find difficult to compete with.

The other options for non-invasive tightening are laserand ultrasound-based. They have their proponents, and in many cases are effective, but it is difficult to top Thermage for quality of effect, predictability of effect, and overall patient satisfaction.

For which patients or presentations is Thermage your “go to” device?

The way I see it, patients have three choices for lower face skin tightening. They can do nothing, have Thermage, or have a facelift. That is how I present it to the patient. The ideal patient is in their late thirties to late fifties, has at most a modest amount of skin laxity, is not too thin or too heavy, and has realistic expectations. They also should be prepared to repeat the procedure every 18-36 months to maintain optimal results.

The new Total Tip 3.0 is intended to aid treatment of the face and neck. What are key features of the new tip and how, in your opinion, does it improve treatment or outcomes?

The new Total Tip 3.0 is extremely comfortable for patients, with an average pain score of 2 on a 1-10 scale. Yet it delivers improved heating, which translates into more impressive skin tightening for the majority of patients. I have also been surprised at how much more quickly results appear after treatment with the new tip. I personally had the treatment, and patients/staff commented that they saw a meaningful difference within two weeks of me having the treatment done.

From a practice standpoint, what features and benefits does Thermage offer that made it especially suited to your clinic?

This is one of Thermage's keys to success in our practice: It is easy for both the patient and provider. The procedure can be performed by physicians or trained allied health professionals, so the ability to delegate affords much needed flexibility to the schedules. It is also nearly painless, and in all cases extremely tolerable for the patient. This improves the patient (and staff) experience, and improves workflow in the office. We have all experienced the disruption in workflow that a patient who is in severe pain can produce. The new Thermage eliminates this variable in a way that other competing technologies are unable to. It is just an easy procedure to incorporate in our practice, and both staff and patients really find it gratifying.

Are there any important considerations in terms of expectation building, pain, or limitations of the device that clinicians should be aware of?

It is essential that clinicians be open about what Thermage can and can't do. This has been one of the keys to our success with Thermage. It certainly helps that the technology works better than ever, and the number of patients in our practice who are disappointed with their results is less than two to four percent. Part of the reason is the power of the technology and quality of results. But another part is that we are very careful to set realistic expectations, not promise results we cannot deliver, and ensure that patients understand what we and Thermage can deliver. This messaging has been essential to the success of Thermage at SkinCare Physicians.

For those physicians who are skeptical, it might be worth taking another look at Thermage. It is one of the most successful procedures in our practice, and both patient and staff satisfaction is exceptional.

Ulthera's Focused Ultrasou nd Ta rgets Deep Tissue

Vivian Bucay, MD

What is Ultherapy?

Ulthera uses focused ultrasound to target the same muscle that plastic surgeons target when they are doing a facelift. What sets Ultherapy apart is that that one can visualize the targeted layer of tissue, whether it be the muscle, or the deep dermal component, or even a more superficial dermal component. This is done by using a series of transducers that deliver very precise energy at regular distances. These can be done at 4.5mm of depth, 3mm of depth, or 1.5mm, which is the newest, most superficial depth.

When I started doing laser resurfacing, back in 1995, people were very happy with the tightening they got in their skin from a CO2 resurfacing, except that they had to be in hiding for about two weeks because their epidermis and upper dermis were completely gone. So we were wishing for something that could lift and tighten without actually affecting the skin and causing a prolonged downtime.

Where does Ulthera fit into your practice? For which patients do you use it?

For me, Ultherapy has very specific roles in my practice. It's for the patient desiring a non-surgical browlift—that was its first FDA approval. But it's also for the patient that wants lifting of the mid- and lower-face along with that area under the chin, as well as the neck. This is the only device on the market that is FDA-approved for lifting of the upper face, the lower face, under the chin, and the neck, as well.

It does not have any downtime whatsoever. The results are gradual, like with many of the things we do.

Are there any challenges associated with Ulthera in practice?

I think the most challenging thing can be setting patient expectations. They will have results, but they have to wait for those results at least three months. I tell patients it's like watching hair grow. If you're looking every single day to see a change, you're not going to see it. Just forget about it, at the end of three months come in, I'll take a look at you, we'll compare your photographs, and we'll take it from there.