Skin laxity is a vexing patient concern. Most patients can point to some area on their body—from their eyes to their ankles—where they are bothered by skin laxity. And to target that laxity, the Thermi platform offers two potential solutions. ThermiTight is a minimally invasive option, where a small probe is placed under the skin for direct heating of tissue. ThermiSmooth uses transdermal energy delivery for broader applications.
For Englewood, CO plastic surgeon Greg Buford, MD, ThermiSmooth, “fits a nice niche…We've been using it both as a standalone and also as an adjuvant procedure to both surgical procedures such as liposuction and tummy tuck, and we've also used it in combination with the ThermiTight.” And the applications truly run the gamut from the face to the feet. The platform is FDA approved for cellulite, although Dr. Buford says he thinks of it more broadly as a tightening device.
“The ThermiSmooth procedure for the abdomen is a wonderful application, which can very effectively tighten the skin to a certain extent, depending upon the patient's tissue quality, their age, the degree of skin laxity. With appropriate patient expectations, overall we have very happy patients for those procedures,” Dr. Buford reports.
“As far as ThermiSmooth, we use it all over the body—on the face, on the arms, on the belly, and on the thighs,” explains New York's Z. Paul Lorenc, MD. “We have a protocol that's pretty aggressive as far as the frequency of delivering the treatment. Typically my protocol is six treatments every two weeks of ThermiSmooth, whether it's thighs, belly or the face.”
Complementary Technologies
While he uses ThermiSmooth or its counterpart Thermi250 as a stand-alone treatment, Dr. Buford believes the device excels when used with other technologies and interventions. For example, he frequently uses a combination to treat laxity in the neck. “We'll use the ThermiTight to begin with to really try to get that initial tightening and then, from there, we'll actually add several sessions with Thermi250 to even further tighten skin,” Dr. Buford says.
Courtesy of Greg Buford, MD
Dr. Buford uses ThermiSmooth around the mouth and around the eyes, coupled with a variety of procedures. “I've had this procedure done myself where we basically use a combination of several sessions of ThermiSmooth around the eyes to essentially tighten that loose skin around eyes,” Dr. Buford shares. “We'll also use direct injection of platelet rich plasma (PRP) to the eye area—both the upper and lower lids—and then we'll microneedle plus PRP to the entire face.”
“I think that's where the Thermi application is really heading. It's very nice as a monotherapy, but I would say that it excels in combination with other therapies, such as microneedling, PRP, surgical procedures, or suture lift. It's really a great adjuvant procedure, and that's really where you get a lot of synergy,” Dr. Buford says. “We already understand now that the system works, so people like me and others are now combining it with other products and procedures to create even greater results.”
Unlike ThermiTight, where the surgeon creates small apertures using either a 16-gauge or an 18-gauge needle to allow entry of the probe to place the energy directly underneath the skin, “with the Thermi250 you use a variety of sized paddles to effectively go through transdermally, down into the tissue. With ThermiTight you're actually directly placing it where you want that heat energy and it's radiating up. Here, you're effectively placing it on the skin and it's radiating down,” Dr. Buford explains.
ThermiSmooth treatment involves minimal discomfort for the patient. “As applied to the body, I think it's a great application of energy. It's comfortable for the patient. Some of the devices are very painful for the patient. Some of the energy based devices are very painful to the patient,” Dr. Lorenc says.
Physician Flexibility
“For a variety of procedures that we're doing now, there's really no right or wrong way to do them. There's a lot of creativity with respect to combining procedures,” Dr. Buford maintains. “A good example is the neck procedures where we're starting out with the ThermiTight and we use ThermiSmooth after. In the past, we just used one. There are people who are just using the ThermiSmooth and there are people who are just using the ThermiTight.”
“Personally, having both devices, I think that you get a one-two punch, and you get more efficacy when you combine them, because you're heating the tissue in a little different manner,” Dr. Buford adds.
As a plastic surgeon, Dr. Buford feels he has “a little bit deeper insight into what can and cannot be achieved with devices.” That understanding is critical, he says, “Because when it comes down to it, expectations are everything. You can't promise your patient something you can't deliver. If you do, you're going to have unhappy patients and you're not going to be able to build your practice clientele.” Certainly there are learning curves in terms of how the procedures are performed, and there's always opportunity to modify the approach. “I've seen people perform the procedures very differently with respect to depth, with respect to the heat energy they start with, the amount of contact time.”
Combination approaches are also important for Dr. Lorenc. “What I love to do specifically on the face is that I use a combination of ThermiTight and ThermiSmooth. Once I finish with the ThermiTight—typically about two, three weeks after that, my aestheticians do a whole sequence of ThermiSmooth on top of that,” he explains. “I think you potentiate the effect of ThermiTight and ThermiSmooth. It's all about energy delivery, so we do the sequence of every two weeks, six treatments of ThermiSmooth after I finish ThermiTight and I think that gives a better result to the patient.”
“The most important factor in achieving optimal outcomes is realistic expectations. That applies to fillers, to toxins, to surgery, to anything,” Dr. Buford emphasizes. “Unfortunately, I think that a lot of times we'll go to meetings and we'll get wowed by technology and we'll just blindly think that it works for everyone, that it's going to achieve the same results that we see in the before and afters. That's not the case. No device performs 100 percent, every time, out of the box.”
“The more you use the device, the more you learn how to push the boundaries with respect to greater duration time or greater contact time, higher energies, higher temperatures, and again, using combinations,” Dr. Buford explains. “As you go on, you really learn how to really finesse the technology, and that's really been the exciting part.”
Dr. Lorenc agrees that the ability to hone technique is beneficial. “We vary the penetration of the heat by adjusting the size of the electrodes on the surface, so the larger the electrode the larger the surface area, the deeper it goes within the tissue. You can melt fat with that. We address cellulite on the thighs, on the buttocks with ThermiSmooth,” he says.
“What I really enjoy is the dialogue between the various users with respect to how they accomplish what they accomplish, because anybody that thinks they've solved everything is kidding themselves. We really do have a lot to learn from each other,” Dr. Buford maintains. “If you learn day one exactly how to do the procedure 100 percent, quite honestly, that would be really boring,” he says.
EXPECTATIONS MATTER
Courtesy of Greg Buford, MD
“I've identified what I can and cannot do and I think that's critical,” Dr. Buford says. “If a patient comes in and they need a neck lift and they have so much tissue laxity that I know I'm not going to be able to affect a positive change, I'm going to tell them that. I don't do neck lifts anymore, so I will refer them.” Dr. Buford explains the patient's need, the limitations or his available technology, and the benefit of surgery when he makes the surgical referral. “I tell the patient that if you look at the curve, they're really outside of the curve of efficacy with respect to what I can achieve with this device alone.”
However, some patients will be satisfied with treatment that is not a “home run.” Some patients simply do not want surgery and are “willing to accept even a small modicum of change,” Dr. Buford acknowledges. “If you have patient like that, that understands, that is cognizant of what the limitations are, then you can use Thermi and you're not going to get a home run result, but quite honestly, you may actually achieve a result that the patient is very happy with.”
Just The Beginning
Thermi, “has all these advantages, so as a source of energy I've incorporated it into my practice and it's the number one energy based device that I use in my practice,” Dr. Lorenc says.
And today's experience may just be the tip of the iceberg. “I do think that combination therapies are really where the aesthetic marketplace or the practice of aesthetic medicine is really heading. At least for those practitioners who are visionaries. There's a lot of aesthetic practitioners who are just cut on the dotted line kind of practitioners that don't expand the boundaries. Quite honestly, I think that's boring,” Dr. Buford says. “I think that the next five, 10 years we're going to see a real revolution with respect to how we're utilizing combination therapy and the types of results we're ultimately achieving for our patients,” he adds.
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