Injecting Energy Into Your Practice
To meet a broad range of patient needs in the aging journey, today’s aesthetic providers need to be armed with both injectable and energy-based treatment offerings. Depending on the patient population, one treatment type may serve as a better door-opener and the other as a trusted tool to keep patients coming back, successfully laying the groundwork for a lifelong patient-provider relationship.
For some first-time patients, injectables can be a great entrée into the world of aesthetic interventions. Not only do injectables, like fillers and neurotoxins, come at a generally low price point, but they are well known to offer immediate results with little to no downtime. Beneficial for providers as well, the frequency of injectables treatments can open the door for discussions of broader indication treatments, such as energy-based devices. With both tools in their arsenal, providers may continue to treat patients synergistically with both injectables and energy-based treatments for broader effect depending on patient need.
On the other hand, access to digital content has accelerated patient savviness for aesthetic procedures. Skewed to a younger demographic than historically shown, this untapped market of patients is more apt to ask directly for laser or other minimally invasive treatments at their first office visits.
“Anyone that searches online and through social media for aesthetic treatments is going to see that energy-based devices have a huge role in anti-aging beauty regimens,” said Stacy Chimento, MD of Riverchase Dermatology in Bay Harbor Islands, FL. “There’s a demand for natural collagen stimulation and rejuvenation solutions with energy devices. This is really the biggest thing that we’re seeing now. Patients want more natural results… subtle useful changes that keep [them looking like] a better version of themselves is really the ultimate goal.”
What exactly is driving this trend? As aesthetic interventions have evolved, the emergence of minimally invasive and low- to no-downtime procedures has expanded the rejuvenation market. Beyond “patients of a certain age” embracing alternatives to surgery to reverse signs of aging, millennials and even Gen Z’s are now discovering the use of injectables and energy-based treatments as opportunities to delay skin aging and maintain their appearance with minimal to no downtime. These groups, brought up on “selfies,” are highly attuned to addressing the often-inevitable changes to pigmentation, loss of facial volume, and collagen degeneration, as are their older counterparts. As a result, the patient base of the aesthetics market has now expanded to include an even wider array of ages - each with their own particular needs.
TREATING THE FULL SPECTRUM
The term “prejuvenation” has increased in popularity in recent years as younger generations understand the value of preventative treatments to slow signs of aging. Historically, energy-based devices (EBDs) had limited roles in the consumer mindset. Even as recently as 2017, 59% of consumers surveyed, even among previous laser patients, were unaware that lasers could be used for acne scars, wrinkles, or tattoo removal, while 66% of them were only aware of EBDs for their role in hair removal.2 With social media beauty treatment images now ubiquitous, and EBDs expanding, consumers are aware of their increasing role in rejuvenation and prejuvenation.
In reality, many energy-based devices have been able to treat the needs of patients of earlier ages all along. Devices used to address scars, wrinkles, skin tone, and texture have been staples of energy-based treatments. Technologies such as Candela’s Sublative RF, for skin ablation, resurfacing, and facial wrinkles, and Sublime treatment addressing wrinkles, are important multi-application technologies used across a variety of patient ages and demographics.4 Today, newer devices, like the Nordlys™ system and PicoWay® laser, treat common patient demands via sophisticated technology that minimizes risk of excessive light,5,6 shortens laser pulses versus earlier generation devices,7-9 and provides the benefit of much shorter downtime compared to some earlier technologies.10-11
(Courtesy of Prof. Michael Drosner, MD)
(Courtesy of B. DeCola)
The Nordlys multi-application platform is the only available device with narrowband intense pulsed light (IPL) and two non-ablative laser resurfacing applicators. Together with a powerful Nd:YAG laser, these technologies create a flexible, risk-minimizing platform treating benign pigmented and vascular lesions, skin resurfacing, and permanent hair reduction.7
On the injectable side, patients’ needs are met with visible results and no- to low-downtime intervention while providers’ desires are met with accessible treatment entry costs and repeat patient visits. But use of injectables alone is quickly becoming a trend of the past. The go-forward for both millennials and older populations is a multi-modal approach—attacking and preventing signs of aging on all fronts. Available injectables cannot address all wrinkles, have limitations for laxity, and show no effect on dyschromia, telangiectasia, rosacea, and other signs of skin aging. Used side-by-side, however, today’s EBDs and injectables can address a broad spectrum of aesthetic needs across age groups.
BUILDING TRUST
The first step of any aesthetic treatment plan is building a strong sense of trust between provider and patient. Energy-based devices may not necessarily provide immediate results, often requiring a series of treatments to achieve optimal outcomes. Therefore, unless a patient enters a practice already familiar with the practitioner’s work or laser treatments in general, energy-based treatments may not be the best place to start. And since success with patients of any age—but especially those new to aesthetics in their 20s and 30s—requires trust to build that long-term relationship, it may be beneficial to first offer patients a more immediate intervention, such as an aesthetic injectable.
“Begin by building confidence in your medical offerings and expertise,” explained Marisha Chilcott, MD, of Morpheus Medical Aesthetics in Northern California. “Neurotoxins or a bit of filler tend to be our entryway in this age group [in particular], because you get to see the patient back in one to two weeks and they are materially improved in their own eyes.”
Dr. Chilcott explains that after patients see results from these initial treatments, it may be a good time to open the conversation to other interventions to address aging, which can take bit longer to show results or have more downtime.
ASSESSING NEEDS
While we often equate wrinkles with skin aging, changes in skin color and tone resulting from broken capillaries or excess pigmentation are often the first visible signs of photodamage. Skincare is essential at any age, and chemical peels may provide benefit for early skin tone concerns. Injectables, such as those with hyaluronic acid, can help replace volume loss and smooth skin. Neurotoxins can soften some lines. However, energy-based solutions may be ideal for a range of early aging concerns across skin tones and often can be used across the entire face and decolletage, as well as body, rather than only in discrete areas.
Today’s patients are interested in maintaining youthful-looking skin and preventing the signs of aging as much as reversing aging. Some react at the earliest signs of telangiectasis or pigmentation, seeking intervention to prevent worsening of skin signs they associate with a parent or grandparent. Some patients simply say they “look tired” due to skin laxity, discoloration, and dark areas under the eyes.
“To turn back the clock and improve the integrity of the skin and its underlying structure, I will often choose the Profound® treatment,” observed Dr. Chilcott.
(Courtesy of Nima Naghshineh, MD, MSc)
The Profound® system offers a nonsurgical alternative to address aging skin using radiofrequency (RF) microneedling. A single treatment provides lasting facial wrinkle reduction and is clinically proven to achieve results that are 37% that of a surgical facelift.12-16 In fact, the Profound treatment has been proven to create up to five times the elastin, twice the collagen, and increased hyaluronic acid.17,18 Plus, the Profound system can be used to improve the appearance of cellulite, offering additional treatment options beyond the face.12
“Patients in their 20s and 30s—especially new moms—may also be candidates for body treatments such as non-invasive radiofrequency with the VelaShape® III system or the Profound treatment,” said Lesley Clark-Loeser, MD of Precision Skin Institute in Davie, FL.
Dr. Clark-Loeser also shared that scars—a common concern in any age group—may be a complaint in younger individuals. She recalled a patient who presented to her office seeking treatment of a scar that resulted following removal of a benign nevus by another provider. “She was getting married, and she had wanted a nevus removed, but then the scar looked worse, in her opinion,” Dr. Clark-Loeser explained. “Using the Vbeam® [laser] on the scar provided great results.”
The Vbeam pulsed dye laser (PDL) is a world renowned, easy-to-use system recognized as the gold standard technology for treatment of vascular lesions. The Vbeam PDL has been proven time and again for the successful treatment of vascular, pigmented, and certain non-pigmented lesions, with a low incidence of side effects.19-31
Lastly, while not specific to aging, many patients are still as interested as ever in laser hair removal. An ideal door opener for providers looking to add energy-based devices to their practice, laser hair removal is a major draw for new patients, many of whom later advance to facial aesthetic treatments, like injectables and laser therapy. The demand for laser hair removal continues to grow each year, including in younger patient demographics and across genders. Despite this, some practitioners have hesitated to add it as an offering due to misperceptions around treatment limitations of darker skin types based on earlier generations of devices.
“It is a mistake to dismiss laser hair removal, especially in the millennial generation,” relayed Dr. Clark-Loeser. “In the past, shorter laser wavelengths risked burning in darker skin tones, but now devices like the GentleMax® Pro system offer both 755nm and 1064nm wavelengths, which really allow us to treat a broad range of skin types, from the lightest to the darkest.”
(Top courtesy of Jill Waibel, MD, bottom courtesy of M. Ercan, MD)
The GentlePro® Series is a trusted laser hair removal solution, built on a foundation of over two decades of success. The leading hair removal brand chosen by dermatologists, it delivers hair removal results providers need, as well as the versatility to treat other indications, such as benign pigmentation and vascular lesions.32,33
A RANGE OF APPLICATIONS
Energy-based devices provide a range of effects, and the array of available devices can address both the “outer envelope” of the skin, as well as deeper skin concerns. For example, Dr. Chimento finds the eTwo system to be a versatile tool for all her patients. She recommends treatment with the eTwo system, which includes the Sublative™ and Sublime™ RF applicators, for millennials to stimulate collagen production to improve skin tone and texture.4,34-38
“I will attest that the eTwo system is one of the biggest ‘guns’ in my office,” said Dr. Chimento. “The results that I am getting for [wrinkles] with eTwo are pretty astounding.”
Combining Sublative RF and Sublime applicators in one ROI- boosting system, the eTwo system allows providers to treat facial wrinkles and restore skin health. In a multi-center study of 72 subjects, the majority experienced improvement in wrinkle reduction and overall facial appearance.4
Discoloration, pigmentation, and even tattoo removal are other common patient concerns related to aging and can be addressed with the PicoWay laser. The system delivers high peak power and ultra-short pulse durations for a photoacoustic effect that transforms skin from the inside out. 10-11,39-41
“The PicoWay device is a workhorse in my office,” said Dr. Clark-Loeser. “It really allows me to broaden my treatment of pigment in almost all skin types. I am much more successful in my treatment of tattoos. I’m able to do a form of non-ablative, very low downtime skin rejuvenation* with the PicoWay Resolve [handpiece].”42
Dr. Chilcott also shared similar experiences with the PicoWay Resolve handpiece. She explained, “For non-ablative resurfacing, the PicoWay laser with the Resolve handpiece creates laser induced optical breakdowns (LIOBs) under the skin that stimulate collagen production.” If needed, hyaluronic acid fillers can be used synergistically under the eyes for a pan-facial effect.
Advanced volume loss and wrinkling may require more robust treatments, even in younger patients. Dr. Clark-Loeser has had success with the CO2RE® laser, a fractional ablative CO2 laser that simultaneously works on the surface and beneath the surface of the skin. It treats a fraction of the skin at a time, making precise, microscopic wounds. As these heal, the body naturally produces collagen and healthy new skin cells. Improvement of texture and skin tone from the CO2RE laser treatment are lasting43-46 and many patients’ results are maintained with occasional injections of filler in target areas.
Dr. Chimento has even used the CO2RE laser for a patient in her 20s who had significant photodamage. “We were able to restore [the patient’s] skin and provide a preventative effect, as well,” explained Dr. Chimento. “We’re building that collagen because after 25, the body doesn’t naturally produce as much.”
(Top courtesy of Nima Joe Niamtu, DMD, bottom courtesy of D. Barco, MD)
A benefit of energy-based devices for the early aesthetic patient in their 20s or 30s is that they do not preclude more invasive interventions in the future; in fact, they could prove complementary.
“You’re now handing that [future] surgeon a better canvas to work with and setting everybody up for more success,” Dr. Chilcott suggested. “We’re treating the envelope, and if you don’t do that, you’re missing a key opportunity.”
A GROWING OPPORTUNITY
While practices can address many of the aesthetic needs of patients of all ages with skincare and injectables, energy-based devices clearly expand the treatment service menu to help deliver optimal results. Used alone or paired with existing offerings, EBDs may even attract younger patients into the practice base and keep older populations coming back, as their needs continue to evolve as they age. More importantly, these devices allow for a range of treatments to meet expanding aesthetic needs.
*Rejuvenation as defined by the treatment or removal of tattoos
1. AmSpa Industry Report 2019
2. BuzzBack Market Research, Sponsored by Syneron Candela, July 2017.
3. Elos plus (510(k) Number K113868)
4. eTwo 510(k) clearance for Sublative RF skin ablation and resurfacing and Sublime for wrinkles (K141507), Dec. 2014.
5. Adatto MA, et al. Curr Probl Dermatol. 2017;52:113-123.
6. Wang CC, et al. J Am Acad Dermatol. 2006;54(5):804-810.
7. Ellipse Nordlys 510(k) clearance (K150907) July 2015, Ellipse Frax 1550 510(k) clearance (K161162) Sept 2016 and Frax 1940 510(k) clearance (K192951) March 2020.
8. Nordlys system instructions for use, 2018. Candela, data on file.
9. Based on 510(k) summaries as of December 2019.
10. PicoWay 510(k) clearance for wrinkles (K170597), May 2017.
11. PicoWay 510(k) clearance for acne scars (K162454), February 2017.
12. Profound 510(k) clearance (K161043), September 2016.
13. Willey A, Kilmer S, Newman J, et al. Elastometry and clinical results after bipolar radiofrequency treatment of skin. Dermatol Surg. 2010;36(6):877-884.
14. Alexiades-Armenakas M, Newman J, Willey A, et al. Prospective multicenter clinical trial of a minimally invasive temperature-controlled bipolar fractional radiofrequency system for rhytid and laxity treatment. Dermatol Surg. 2013;39(2):263-273.
15. Alexiades M, Berube D. Randomized, blinded, 3-arm clinical trial assessing optimal temperature and duration for treatment with minimally invasive fractional radiofrequency. Dermatol Surg. 2015;41(5):623-632.
16. Blinded, random ized, quantitative grading comparison of minimally invasive, fractional radiofrequency and surgical face-lift to treat skin laxity. Alexiades M, Rosenberg D, Renton B, Dover J. Arch Dermatol. 2010; 146(4):396-405.
17. Hantash BM, Ubeid AA, Chang H, Kafi R, Renton B. Bipolar fractional radiofrequency treatment induces neoelastogenesis and neocollagenesis. Lasers Surg Med. 2009;41(1):1-9.
18. Willey A, Kilmer S, Newman J, et al. Elastometry and clinical results after bipolar radiofrequency treatment of skin. Dermatol Surg. 2010;36(6):877-884.
19. Vbeam 510(k) clearance (K033461), January 2004. Vbeam Prima 510(k) clearance (K180593), June 2018. Vbeam Prima 595 nm Treatment Indications: Photocoagulation of benign cutaneous vascular lesions, Photocoagulation of benign cutaneous lesions, Facial telangiectasia, Leg telangiectasia, Rosacea, Port wine stains, Hemangiomas, Angioma, Spider angioma, Poikiloderma of Civatte, Warts, Scars, Striae, Psoriasis, Wrinkles, Benign epidermal pigmented lesions, Inflammatory acne vulgaris.
20. Vbeam Prima 1064 nm Treatment Indications: Port wine stains, Hemangiomas, Warts, Telangiectasia, Rosacea, Venous lakes, Leg veins, Spider veins, Poikiloderma of civatte, Lentigos (age spots), Solar lentigos (sun spots), Café au lait macules, Seborrheic keratoses, Nevi, Chloasma, Verrucae, Skin tags, Keratoses, Periocular wrinkles, Perioral wrinkles. Candela, data on file.
21. Vbeam 510(k) clearance for pigmented lesion handpiece accessory (K051359), July 2005.
22. Vbeam Prima 1064 nm Treatment Indications: Port wine stains, Hemangiomas, Warts, Telangiectasia, Rosacea, Venous lakes, Leg veins, Spider veins, Poikiloderma of civatte, Lentigos (age spots), Solar lentigos (sun spots), Café au lait macules, Seborrheic keratoses, Nevi, Chloasma, Verrucae, Skin tags, Keratoses, Periocular wrinkles, Perioral wrinkles. Candela, data on file.
23. Bernstein EF, Kligman A. Rosacea treatment using the new- generation, high-energy, 595 nm, long pulse-duration pulsed-dye laser. Lasers Surg Med. 2008;40(4):233-239.
24. Woo SH, Ahn HH, Kim SN, Kye YC. Treatment of vascular skin lesions with the variable-pulse 595 nm pulsed dye laser. Dermatol Surg. 2006;32(1):41-48.
25. Chapas AM, Eickhorst K, Geronemus RG. Efficacy of early treatment of facial port wine stains in newborns: a review of 49 cases. Lasers Surg Med. 2007;39(7):563-568.
26. Jasim ZF, Woo WK, Handley JM. Long-pulsed (6-ms) pulsed dye laser treatment of rosacea-associated telangiectasia using subpurpuric clinical threshold. Dermatol Surg. 2004;30(1):37-40.
27. Jørgensen GF, Hedelund L, Hædersdal M. Long-pulsed dye laser versus intense pulsed light for photodamaged skin: a randomized split-face trial with blinded response evaluation. Lasers Surg Med. 2008;40(5):293-299.
28. Halachmi S, Israeli H, Ben-Amitai D, Lapidoth M. Treatment of the skin manifestations of hereditary hemorrhagic telangiectasia with pulsed dye laser. Lasers Med Sci. 2014;29(1):321-324.
29. Yu W, Ma G, Qiu Y, et al. Prospective comparison treatment of 595-nm pulsed-dye lasers for virgin port-wine stain. Br J Dermatol. 2015;172(3):684-691.
30. Galeckas KJ, Ross EV, Uebelhoer NS. A pulsed dye laser with a 10-mm beam diameter and a pigmented lesion window for purpura-free photorejuvenation. Dermatol Surg. 2007;34:1-6.
31. Madan V, Ferguson J. Using the ultra-long pulse width pulsed dye laser and elliptical spot to treat resistant nasal telangiectasia. Lasers Med Sci. 2010;25(1):151-154.
32. American Society of Dermatological Surgery Survey, 2014.
33. Gentle Pro Series, 510(k) clearance (K140122).
34. Data on file, Candela.
35. ePlus Skin Treatment System 510(k) clearance (K113868), June 2012.
36. eTwo Skin Treatment System 510(k) clearance (K110672).
37. Gold AH, Pozner J, Weiss R. A Fractional Bipolar Radiofrequency Device Combined with a Bipolar Radiofrequency and Infrared Light Treatment for Improvement in Facial Wrinkles and Overall Skin Tone and Texture. Aesthet Surg J. 2016;36:1058-67.
38. Gold MH, Biesman BS, Taylor M. Enhanced high-energy protocol using a fractional bipolar radiofrequency device combined with bipolar radiofrequency and infrared light for improving facial skin appearance and wrinkles. J Cosmet Dermatol. 2017;16:205-209.
39. PicoWay 510(k) clearance for benign pigmented lesions (K150326), April 2015.
40. PicoWay 510(k) clearance for tattoos (K142372), October 2014.
41. PicoWay 510(k) clearance for tattoos with 785 nm handpiece (K160607), July 2016.
42. Rejuvenation as defined by minimization of benign pigmented lesions, wrinkles and acne scars.
43. CO2RE Laser System 510(k) clearance (K151655), September 2015.
44. Mahlberg MJ. Rhinophyma—CO2RE Laser. Candela, data on file, 2015.
45. Friedman D. Ablative fractional skin resurfacing and facial scar reduction with the CO2RE device. Candela, data on file, 2015.
46. Arroyo C. CO2RE laser for burn scar and striae distensae patients. Candela, data on file, 2016.
47. VelaShape III is FDA-cleared for temporary reduction in the appearance of cellulite and temporary reduction in thigh circumference. VelaShape III 510(k) K122579, February 2012.
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