The New Age of Devices: Challenges and Opportunities

Arguably once thought of as niche, aesthetic devices are now essential tools in the increasingly nuanced spectrum of cosmetic care. They can be used in various capacities, from resurfacing and rejuvenation to skin tightening and body contouring. In particular, recent years have seen the development of new modalities as well as new approaches for integrating established technologies.

Over the last several months, several experts on the use of aesthetic devices participated in the video program “Device Talk” for ModernAesthetics.TV. In each edition, two physicians discussed their experiences and offered tips for maximizing results, addressing topics as varied as ablative resurfacing, tattoo removal, body contouring, and treating darker skin types. Here are highlights from the series.

Ablative vs. Nonablative Resurfacing

According to Jeffrey Dover, MD, the demand for ablative laser procedures has dwindled at a similar rate as the demand for nonablative procedures increased. “I was doing a lot [of ablative procedures] 20 years ago, not so much 10 years ago, and now hardly at all,” he notes. Sometimes Dr. Dover will perform localized ablative procedures, but much of the time, he says, he attempts to convince patients to avoid ablative procedures, since the risk/benefit ratio is much greater with ablative procedures.

According to Arielle Kauvar, MD the role of ablative procedures may be diminished, but it still exists. She notes that ablative modalities can be effective for surgical scars and traumatic scars. Another benefit of ablative procedures, she says, is the repigmentation in white scars. Dr. Dover notes that ablative lasers can also be effective for localized treatment of perioral lines, but rarely periorbital lines due to the downtime.

Dr. Kauvar also notes the utility of low-density ablative devices for resistant tattoos. “If [the patient has] hit a will with a Q-switch [laser], I will then go to ablative fractional resurfacing. It's really the same wound care for healing after Q-switch or Picosecond laser, and they do very well,” she says. “Any textural change improves as well.”

Although ablative fractional procedures can be effective for scars, Dr. Dover notes that they have somewhat fallen out of favor due to downtime, which is all the more glaring when compared to nonablative procedures. “My feeling is that six of [nonablative treatments] you get as good or better [than an ablative treatment]. The downtime is cumulatively about the same, but it is easy to take a weekend off; it is harder to take 10 days off.”

However, despite the improved utility of nonablative procedures for scarring and mild to moderate photoaging, results can be disappointing for anyone with severe lines. “For these procedures, we need some combination of treatments, including ablative, if they are willing to do it,” says Dr. Dover. For patients with acne scarring, Dr. Kauvar says that nonablative fractional treatments are ideal. “For individual with moderate to severe scars, I always combine that with sessions of subcision as well,” she notes.

Dr. Dover points out that there may be differences in efficacy between ablative and nonablative procedures, as well. “There is no doubt that the six [nonablative] treatments slowly but surely modulate the scars, whereas the one ablative procedure doesn't do as much and the downtime, still, while way better than it used to be, is still a while,” he notes.

Dr. Kauvar points out several mechanistic differences between the procedures. “We use ablative fractional [devices] for hypertrophic burn scars where there is tension on the scar and we want to relieve the tension. Then those channels fill in with new collagen and we're actually increasing surface area of skin where we want to decrease surface area of skin,” she says. “Certainly the interaction with different types of tissue can be different, but you have to wonder even though you see more collagen deposition, are you getting more tightening with the ablative fractional?”

Fat Reduction and Body Contouring

Within the last several years, body contouring technology has ingrained itself not only in the vast spectrum of device procedures, but as a major new force in the wider practice of aesthetics. “What's remarkable about this field is that it didn't really even exist five years ago,” says Mathew Avram, MD. “There were really no non-invasive devices that worked or had FDA approval for fat specifically. But if you look at ASDS data from 2013, nearly 75 percent of procedures are being treated non-invasively. So this is a paradigm shift,” says Dr. Avram.

There are now several devices on the market, Dr. Avram observes, and each is slightly different when it comes to how the fat is treated. “With cryolipolysis (CoolSculpting by Zetiq), the target is fat by temperature. With cooling at certain temperatures, you can have a controlled decrease in fat in a treated area,” says Dr. Avram. “What we've found in studies is that repeat treatments and larger areas can yield significant sculpting at a higher price point for the patient,” he continues. However, according to Mark Rubin, MD, repeat treatments may not be necessary for all patients. “For some patients, a single treatment is sufficient,” he notes. “But the average patient is probably treated twice,” Dr. Rubin explains.

Other devices include high intensity ultrasound (Liposonix), in which “heat from the ultrasound kills fat cells at 1.3 centimeters below the skin surface,” says Dr. Avram. “This is a more painful procedures but it molds to different areas, so patients who may not be appropriate for cryolipolysis can use ultrasound.”

Another procedure is selective radiofrequency (RF), which includes devices such as Vanquish and Exilis (BTL Industries). “With regard to Vanquish, I've seen people consistently come every two weeks who have a 45-minute treatment on a certain area… and they lose at least two inches in six treatment settings,” says Jeanine B. Downie, MD. “We weigh them every time and measure them every time and we let them know where they are, what's happening and we encourage them to hydrate,” Dr. Downie notes.

With the explosion of devices in the treatment of fat over the last several years, Dr. Avram notes that there are several important facts to consider before jumping in. The cost of the device is one of these, along with cost of disposables, which can become very expensive, he suggests. Also, “What is your patient population and do these procedures treat that?” says Dr. Avram. These are all important questions to investigate while these devices are still in their infancy.

Nevertheless, there is no doubt the market is ripe for these procedures. And according to Dr. Rubin and Dr. Downie, that could be a boon for other cosmetic procedures, as well. Says Dr. Downie, “I do feel like a lot of people hit the door for body contouring and stay for the Botox or filler.” Dr. Rubin agrees that patients who arrive at the practice for fat reduction treatments and then leave are pretty uncommon. “Often, patients come in for contouring, they get good results and they have a good feeling for you and the practice, and I'd say about 90 percent of patients end up having another procedure,” says Dr. Rubin.

Challenging Cases in
Device-Based Treatments

Despite the many advances in laser and device technology in recent years, there are still challenging cases in which great results often prove elusive. For example, according to Vic Narurkar, MD, treating darker skin can be difficult. “Treating darker skin for both pigment and vessels can be a challenge, particularly Asian skin, which tends to have the highest incidence of PIH.”

According to E. Victor Ross, MD, going “lighter” may be key to better outcomes in these patients. “If they have fixed vessels, I use a very small spot KTP laser or even ND:YAG with relatively conservative settings to take some vessels out,” says Dr. Ross. “The rest of the face, if they have melasma, is very challenging to treat. Using a triple bleaching cream first, Dr. Ross then typically uses low energy fractionated resurfacing in these patients, sometimes combined with KTP or IPL devices. However, he warns that operators have to be very conservative with these treatments because they could make the condition worse.

Lentigines tend to be somewhat easier to treat, Dr. Ross notes. “I usually try to use a long pulse green laser or Q-switched laser, but very gently. I tell patients they may get some PIH. I usually hit them hard with type 1 steroid for a week or two afterwards, but even then may get some PIH,” says Dr. Ross. Overall, though, Dr. Ross calls this a “tough group” to treat, and there is no perfect recipe.

Dr. Narurkar is often very upfront with these patients during the consultation that this is a process and that a lot of those spots may not fade. “I'd rather have a few bounce-backs than make them darker or worse, yet, create hypopigmentation,” Dr. Narurkar observes.

Vascular Treatment

For vascular cases, Tina Alster, MD notes that many lasers are available that can yield good results, including pulsed dye, IPL, green light, KTP, and ND:YAG. “Whether a patient has telangiectasia or flushing, we have different lasers for each nuance,” she says. For more diffuse redness, Dr. Alster prefers something that treats the whole cheek, such as an IPL or pulsed dye laser. “For more discreet telangiectasias, I may use an ND:YAG for spot treatment and then I use 595 pulsed dye or KTP laser for individual telangiectasias,” says Dr. Alster.

Deciding whether to prescribe topical therapy prior to laser treatment depends on the appearance of the patient and what the patient has undergone already, Dr. Alster observes. Nevertheless, no matter the stage at which laser treatment is introduced, Dr. Alster stresses that education is essential. “It is important to educate patients as to what rosacea is,” according to Dr. Alster, and that “it often takes two to three treatments to knock back 80 percent of the vessels, but they could come back.” Treatment is an ongoing process, she stresses. “Sometimes it is not retreated vessels that are coming back but new ones.” Therefore, says Dr. Alster, “we need to prepare patients for multiple treatments as well as some sort of maintenance, as some things can worsen or recur with age.”

CombO Therapy:
Red and Brown Spots

Combination laser regimens appear to be gaining in popularity. For red and brown spots, Dr. Narurkar likes to combine vascular laser and IPL. “I find that the lasers are very precise for treating isolated capillaries and then I use IPL to treat the background facial canvas and sometimes even Q-switched for pigment,” says Dr. Narurkar. “Another favorite combination is to do fractional for resurfacing and then go over the capillaries with IPL or vascular laser either on the same day if I'm doing nonablative or a different day if I'm doing ablative resurfacing. Combining devices for red and brown is probably some of the most popular things we do in the office,” says Dr. Narurkar.

Visit www.modernaesthetics.com/series to see the full discussions.

Device Talk Pearls

Jeffrey Dover, MD on treating scars ablatively:
“Low fluence is the key. The only problem with ablative fractional is where physicians treat aggressively thinking they need to go aggressive for a thick scar, and they actually cause inflammation... and worsening of the scar.”

Vic Narurkar, MD on combining laser treatments with injectables: “If I'm doing IPL or treating vascular pigmented lesions, I will do Botox on the same day. With fractional lasers, I find that I often stage them… sometimes you can get diffusion of botolinum toxin. The same goes for fillers. I'll do the filler first and then do my vascular laser or IPL resurfacing in a staged fashion.”

Arielle Kauvar, MD on fractional ablative technology: “I won't take fractional ablative as first-line treatment if someone has hypertrophic or keloidal scars, because those patients are most susceptible to being activated by high energy treatment.”

Mark Rubin, MD on fat treatments:
“I've found that anytime we do anything that's involved with fat reduction, it's sort of an excuse for people to eat. We do remind them of that and weigh them just to keep them on track so that at the end of that time and we compare the before and after, it's really a valid one.”

Tina Alster, MD on differences between fat and cellulite: “It can be hard to figure out which to treat: You treat fat and maybe also cellulite, but they can be mutually exclusive. Virtually everyone who comes in has a little bit of cellulite, which can be treated with non-invasive machines—mechanical rollers and slow heating systems—which are temporary but show some improvement.”

E. Victor Ross, MD on picosecond technology:
“Tattoos won't be enough to sustain the momentum. We have to find other applications—such as melasma or non-invasive rejuvenation—to enhance role of picosecond lasers.”