Taking the Pulse of Device-Based Aesthetic Procedures

E. Victor Ross, MD is Director of the Scripps Clinic Laser and Cosmetic Dermatology Center in Carmel Valley, CA.

The current environment of device-based aesthetic procedures is difficult to characterize. On one hand, things are relatively ‘status quo' and have not changed too dramatically, with some exceptions. However, we are also seeing a gradual evolution of light-based procedures and other forms of technology that are slowly shifting and expanding the direction of the field. We are not seeing massive leaps from the standpoint of the technology of these devices. However, advances in accessibility and convenience may indeed have a measurable impact on the world of device-based interventions in cosmetic medicine.

Ahead, I will examine some of the latest trends in the laser- and other device-based treatments and offer strategies for integrating devices into your practices and also for communicating with patients.

A Continued Evolution

The newest developments in device-based technologies span a variety of modalities. A detailed discussion of specific technologies will follow later in this article, however some broader trends and directions based on the latest releases are worth noting. Perhaps in response to clinician and patient desires, much of the latest developments emphasize portability and shortened duration of procedure. For instance, the Syneron Core is a small and light CO2 laser that can be moved quite easily from room to room (almost as readily as a hyfrecator). There also are multiple beam shapes and patterns and a somewhat unique “fusion” mode, where both deep smaller wounds and more superficial broader wounds are created simultaneously. Another device that's received positive feedback is the UltraPulse Fractional C02 Laser (Lumenis) because it allows clinicians to treat large areas very quickly, which is ideal for certain procedures (i.e. full leg rejuvenation).

Outside of these general advances, other innovations are opening up entire new areas of treatment for aesthetic clinicians. These include tattoo removal and fat reduction, which I'll discuss ahead.

Advances in Tattoo Removal. Tattoo removal is an area of device-based procedures that is seeing great strides of late. Picosecond lasers, such as PicoSure (Cynosure), for example, could be a viable solution to the current problem of laser tattoo removal requiring too many treatments. In theory, these lasers could fully remove tattoo ink in one to three treatments, which would revolutionize tattoo treatments if this speculation were realized. They may also help treating certain tattoo color types known to present challenges for our existing repertoire of devices. These fast lasers might also prove useful for pigmentary disorders and rejuvenation.

Another recent advancement in tattoo removal is application of the topical agent perfluorodecalin to Q-switched laser treatments. Often when you treat a tattoo, the treatment leaves a white area. But perfluorodecalin may cause this whiteness to dissipate relatively quickly. Furthermore, the addition of this agent may also speed up the entire tattoo removal process, with the whiteness being gone within seconds after irradation, so that additional treatments (at the same visit) can be performed quickly. Fractional lasers have also enhanced tattoo removal, often in concert with Q-switched lasers.

Tissue-tightening Technologies. We're also seeing continued development in the world of tissue-tightening and fat reduction technologies, however we have not seen one or two devices declared as the absolute leaders in this realm. Ultrasound technology has created some buzz, however its capacity is limited in terms of what it can treat and how it is used. Having said that, Ultherapy (Ulthera) has recently introduced new treatment algorithms that appear to yield better results. Essentially, the new algorithms enable operators to do more lines with different transducers, which allow them to go to different depths (roughly 3-5ml deep in the skin). With its new algorithms, Ultherapy represents a case in which you can achieve different results in skin tightening simply by changing how the machine is used.

Another relatively new treatment in the broader tightening realm is Cynosure's Cellulaze, which was approved in 2012. Treatments appear to be effective for both cellulite and possibly tightening. Cellulaze for cellulite is somewhat laborintensive and time-consuming, however, the results for these challenging conditions can justify the effort for both clinicians and patients. An RF technology (Thermigen) also is being studied for cannula-based neck tightening with real time temperature feedback.

Aids and Add-Ons. Advancements in the aesthetic device realm are not limited to the devices themselves. Sometimes add-ons and other supplemental pieces can provide added efficacy or convenience. For example, Palomar's (now a Cynosure company) Skintel Melanin Reader gives a real-time guide that measures pigment in three measurements. Once it determines the pigment, it sends the signal to the IPL device and gives the clinician a reasonable setting to use as a starting point. This can help to avoid over- or under-treatment. Other new aids being integrated into devices now include wireless connections and other features that aid in assessment or conveniences during the actual treatment.

Emerging Combination Approaches

One very interesting trend that's started over the last year or two is what appears to be an emerging treatment algorithm for rejuvenation of the face that involves treatment with a device in addition to treatment with botulinum toxins and fillers. If these procedures are performed appropriately and in the right order (toxin first, filler second, laser last), all three can be used in the same session. It's the equivalent of “one-stop shopping” in aesthetic medicine and it can provide very good results. How much you use or inject in each session will depend on the patient and the specific goals of treatment, however, the general rule I apply is that toxins may be used in the upper face and fillers in the lower face to re-volumize. Then, you can introduce a laser treatment, which the results of which can couple very nicely with the toxins and fillers.

While combination approaches utilizing a variety of cosmetic modalities can offer immediate results, it's important to be mindful of how each product or procedure may affect the others. If you do too much in one session, problems may arise. For example, if you are injecting neurotoxin, a laser that causes significant swelling can actually diffuse the toxin and diminish the effect or cause eyelid drooping. That's why it is important to inject the toxin first and select a device carefully that can compliment the toxin rather than potentially diffuse it. For example, fractional ablative laser may result in diffusing the toxin away from where you want it to be. However, if you feel that a procedure that's associated with more swelling is warranted in a specific situation, it might be more prudent to defer on the toxin until the following visit or sometime later.

After treatment with toxin and filler, the types of devices that I find are most effective and complementary are pulsed dye lasers and some non-ablative IPL or KTP (green light) lasers for red and brown colors. Then, nonablative fractional devices tend to be very effective. This is my default regimen for about 50-60 percent of patients who do not want downtime. I have observed that patients increasingly are requesting procedures associated with less downtime. That rules out many ablative procedures, which, by definition, are open-wound. Some devices are not inherently ablative or non-ablative, but instead provide variable results depending on how aggressive you are with them. The UltraPulse, for example, is one of these devices. However, sometimes the extent of treatment that patients require in order to achieve their desired outcome will require ablative intervention.

At this time, the role for combinations of fillers, toxins, and device-based procedures is growing. The reason for this is that each procedure has unique benefits that the others do not. They complement each other with very little overlap. Patients may request just one or two of these, but with an approach that incorporates a well-designed regimen of all of these therapies, the results can be profound. With eight to 10 different fillers, three toxins, and over 100 lasers available, it can be difficult to choose and find the right approach, but the key is to keep it simple and recognize the strengths of each modality and how it may complement the others.

Integrating Devices Into Practice

Given the sheer number of aesthetic devices currently on the market, deciding on which to integrate into your practice can be a daunting task. It's important to do your research before selecting a device. Some devices may be appealing because they offer a broad capacity of services, others because they are less invasive, or perhaps cover more surface area in less time. Then there is cost, which is important but shouldn't be the main reason for investing. Some of the more “low-end” devices may be attractive based on cost but should sometimes be avoided. All of these factors should be weighed individually and against each other in order to determine what works best for your practice. Seeing a device in action also boosts your ability to determine whether it's a good fit. You can do this at the annual meetings of American Academy of Dermatology (AAD), the American Society for Aesthetic Plastic Surgery (ASAPS), the American Society of Laser Medicine and Surgery (ASLMS) meeting, and others. A good relationship with your local manufacturer representative can also be very beneficial, as some may allow you to sample the machine in your practice.

The most useful analogy I can think of when it comes to navigating the crowded market is to think of devices like a baseball team. You're going to need a pitcher, a catcher, infielders and outfielders. In other words, there are some base functions that you're probably going to need filled if you want to cover a range of aesthetic procedures. Thus, it may be wise to have a device for each broad category.

For example, treating red and brown spots is one of the most basic and important functions to offer, therefore it makes sense to offer any of the visible light technologies, which include pulsed dye lasers, IPL lasers, or large spot KTP lasers. A number of lasers in all three of these categories can provide very good results. In the ablative arena, the RF Pixel (Alma) and a large array of the CO2 and erbium YAG/YSGG lasers both cover a range of fractional procedures.

Fractional technology has received great emphasis in recent years, as evidenced by the wide range of fractional devices on the market. Radiofrequency (RF) technology also continues to be a popular avenue of devices, and they tend to run cheaper than laser based fractional devices. A select number of devices offer fractional technology in a RF device, such as Syneron's eMatrix and Alma's RF Pixel, and the Invasix Fractora. It is likely that fractional technology (particularly of the RF variety) will continue to grow, given that they are relatively cost-effective to manufacture and provide reasonably effective results on the whole. As with any technology, however, there is no one device or technology that treats the gamut of skin conditions. We will likely see more non-ablative technologies flourish in the future, but the most important thing is to select technologies that are complementary and allow you to treat a range of conditions.

Still Improving

The vast landscape of device-based therapies we can now offer to patients has given us fresh possibilities for how to treat a range of conditions. Given how rapidly we've seen the field grow and develop, we now have a clearer picture of what still needs to improve. Thus, as we await further developments in the world of skin tightening and non-invasive fat reduction, it's important to take note of the smaller advancements that are making treatment easier for both us and our patients. And generally, although we may become masters of certain technologies and procedures, we all benefit from a greater willingness to learn as the evolution of device-based procedures continues.

Dr. Ross has disclosed relationships with Palomar, Lumenis, Alma, Sciton, and Syneron.