Lifting Without Cutting #1: The Biology of Non-surgical Lifting

PA052 Lift, But Don't Cut.txt
Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, a podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is Lift, But Don't Cut. All right, Dr. Bass, you've piqued my curiosity yet again. What are we talking about in this episode?

Dr. Lawrence Bass (00:31):
Well, Doreen, this episode is about the technologies available for non-surgical lifting and about the biology behind that process. It's also about where we stand with these technologies and how to think about the best ways to use them because that's really critically important to success when it comes to non-surgical lifting. I've often said from the lecture podium that this is the holy grail of plastic surgery, the ability to lift the face and neck skin without surgery. That's something most of us would be interested in, a far larger group than those who are actually undergoing the facelift surgery itself.

Doreen Wu (01:18):
Where do these technologies for non-surgical lifting come from? I'm ready for my history lesson.

Dr. Lawrence Bass (01:24):
We saw flickers of skin tightening possibilities from various skin smoothing treatments, things that were designed to treat wrinkles, so things like chemical peels and laser peels. We would notice if you did a pretty deep aggressive peel in addition to smoothing out or ironing out some of the wrinkles, the skin would be modestly tighter. So that piqued everyone's curiosity and got them interested in looking at how to make that into a treatment in and of itself. In the 1990s, there were multiple attempts using lasers and other infrared light sources to create a controlled thermal injury in the skin that would then heal with tighter lifted skin.

Doreen Wu (02:22):
During this time period in the 1990s, did any devices come out for skin tightening?

Dr. Lawrence Bass (02:27):
Well, not per se. There were some attempts using neodymium YAG lasers and infrared light sources, but the approvals from FDA, or clearances, were always for tissue heating or tissue coagulation because the manufacturers basically showed that they were equivalent to antecedent devices in terms of their ability to create tissue heating, and that allowed them to get on the market while avoiding the need to prove the safety and efficacy of skin lifting. And FDA has an issue with the notion of tightening. We talk about tightening all the time. The FDA has an issue with this nomenclature of tightening versus lifting. So we talk about tightening all the time, plastic surgeons and their patients. People understand when their skin is tight and when their skin is loose and saggy. But to FDA, the ability to create a scientific definition and proof for tightening the skin has not been something they've been able to sort out.

(03:51):
They have permitted the use of the term lifting because that takes skin that's sitting in one position and moves it to a different position, and that can be measured and proven. And so FDA in more recent years has provided lifting clearances for a number of devices, and I think part of the confusion comes out of the issue of thinking about skin and they're trying to understand how can you tighten skin, but skin is not really static like a piece of cloth. It's dynamic. It has elastic response both in the short term and for long-term stress effects. So if you pull on your skin, it stretches a little and expands and then it shrinks back. If you stretch it long-term like with pregnancy or plastic surgeons who use tissue expanders that are temporary saline bags that are placed under the skin, slowly blown up to create extra skin for reconstructive plastic surgery, we know that skin can stretch quite a bit if it's put on sustained stretch over weeks and months.

Doreen Wu (05:11):
So when did the modern era of non-invasive skin treatments really begin?

Dr. Lawrence Bass (05:17):
This was in the early two thousands with two events. One was the introduction of a device called Thermage, and another was the, at just about the same time, the first introduction of fractional energy-based treatments. So Thermage basically started as a single depth radiofrequency treatment. A handpiece was held against the skin radiofrequency energy was put in to create a controlled thermal injury at the deep edge of the skin. And this got approvals for things like crow's feet in the lateral eyelid area, but also to lift the brow and elevated from its baseline position, and then fractional treatments or treatments that instead of exposing the entire area, expose only a portion of the skin broken up into small shapes like pin dots with skip areas in between, which allows you to create different effects in the skin than what might be tolerated or what might heal. Well, if it was a full field treatment,

Doreen Wu (06:43):
Where did it go from there?

Dr. Lawrence Bass (06:45):
So the next lifting devices, which actually ended up with actual lifting clearances from FDA, were Ultherapy and more recently Sofwave. So Ultherapy is a fractionated ultrasound treatment that creates multiple dots of thermal injury at defined depths under the skin. So it's fractionated and it's multi depth or multilayer in its treatment. Sofwave, which has become available more recently, also uses sound energy and creates fractionated exposures at a single depth under the skin, but covering a greater cross-sectional area.

Doreen Wu (07:37):
So far, all of the treatments we've talked about are non-invasive, which is good for people who aren't ready to undergo surgery. But you mentioned it can be difficult to amplify the effect using these treatments. Can you talk about why that is?

Dr. Lawrence Bass (07:51):
Well, the issue is the degree of laxity that somebody has and what data these devices have available. The data is produced in a certain population of patients with a certain age range, a certain degree of laxity, and you can't necessarily crossly that to other types of patients. It's also about some of the biology and how the body responds to the energy exposures that are involved. So as I said, each of these technologies creates a controlled thermal injury. The body recognizes that the tissues have been heated up and in some way damaged and it initiates a healing response. That healing response creates new collagen, and the new collagen, like thousands of tiny guidelines under the skin creates lifting by pulling the skin tighter, smoother, and lifted. And it's partly a product of what depth it's done at. It's partly a product of how much of that response you can stimulate.

Doreen Wu (09:11):
Speaking of biology, let's talk about how these technologies work. Can you break it down for me?

Dr. Lawrence Bass (09:17):
So this is really important. It is about the biology. It's about the biology of how our skin changes as we age. It's also about the biology of how our skin responds when it's pushed with these controlled thermal injuries. So I call this the Thermage lesson because it really came out of some of the early experience with Thermage. Number of people using the device we're trying to amplify the response. So they said, well, if a little energy is good, more must be better. And at that time, the treatment was a single pass and a single treatment.

(10:04):
So that means each area of skin that you were trying to lift would be touched with the handpiece once and have an energy exposure. And at the end of one treatment, you were hoping the patient would go home and the body would add new collagen for a few months and lift them. And what happened when people tried to turn up the energy to get more response was the complication rate went up significantly. But the biological response in terms of lifting was really not much better, incrementally better, but not much. So the lesson was more complications not acceptable, especially for a cosmetic treatment. So a number of people with experience with the technology met with the company, put their heads together, and they figured out that dialing down the energy but doing multiple passes going over the skin more than once was much safer, but it pushed the response harder, and then they likewise considered circling back in six weeks and doing a second treatment.

(11:22):
This actually improved the clinical response and took the complications almost to zero. So that's a very important lesson about biology and what it means is you can, at a certain threshold of injury, you can turn the response on, but you can't amplify it by adding more energy or going to a higher temperature. It's like flipping a light switch. If you push on the switch but not hard enough, the light's going to stay off. And once you push it hard enough to flip it up, the light's going to go on and flipping it up harder or faster doesn't make the light anymore on, and unfortunately, the biology of this kind of skin remodeling, that's how it works. The other thing I said is biology as we age and remodeling is something we're doing actively all the time with our skin. We do it faster and more effectively when we're younger, we do it slowly or more slowly and less accurately and less completely when we're older.

(12:31):
So we can't turn back on the full response we had, let's say at 20 years old, and even if we did, it wouldn't stay on for long. We need to keep repeating the stimulus of the energy treatment to keep the response on. Also, the stimulus has to be working for a long time to make a big change. Remember, we lost our remodeling and then got saggier and saggier over decades, and this isn't going to fully reverse even in a few months. So with this slower skin biology, the rational way to do these treatments is to push the skin periodically over and over, not just push it once really hard. So it's like that Thermage lesson. We learn multiple passes at low energy or better than one pass at high energy. Multiple treatments over time, periodically are going to be better than just one really aggressive treatment.

(13:37):
The problem is this doesn't really match the business model of the devices or how they're being used in the United States. This is again, the business decisions of the companies and it's the temperaments of the doctors and the patients. I'm a New Yorker, we're impatient, we're busy, we want it fixed and get on with things. But unfortunately, that's not how it's going to work with non-surgical lifting until we really find a different approach for non-surgical lifting. I believe it's best done as a process and other countries in the world take much more of that approach when they use these devices and have had actually often impressive levels of success with it.

Doreen Wu (14:27):
Are there alternatives to a full open surgery like a facelift or a neck lift, something that will provide comparable results?

Dr. Lawrence Bass (14:35):
So we've been talking about applying the energy externally, but you can also apply energy under the skin in a minimally invasive fashion. So devices like FaceTite, which uses radio frequency energy in a minimally invasive fashion are able to place a great deal of energy right under the skin, right where you need it in a safe fashion. You don't have to get it through the skin safely because you're delivering it directly where you need it, and that might be a next step up depending on the degree of laxity that you're showing, showing where the degree of response you're hoping to get.

Doreen Wu (15:14):
After our discussion today of all these different non-surgical lifting options, in your opinion, Dr. Bass, is the facelift outmoded? If not, why isn't it?

Dr. Lawrence Bass (15:25):
So as I said previously, there's really no substitute currently or on the horizon that can give the degree of laxity correction for people with significant laxity in the jowl, jawline, or neck areas. Facelift is really the big facial reset and has the ability to make a major change in one step with a great deal of durability a decade or longer typically. So there's nothing else we have that can do that for people that have already reached that point in the aging continuum, they're still looking at a facelift, but for people who are not there yet, they still have the option to pursue a more limited alternative like what we've been discussing in this episode.

Doreen Wu (16:24):
Lastly, Dr. Bass, can you give our listeners some parting takeaways from this episode?

Dr. Lawrence Bass (16:29):
So all of these treatments are extremely useful and it's great to have them available, but they only give you what you are hoping for if you are a good candidate for that treatment. So if you are 80 years old and pushing your skin with energy is not going to get much biological response because your skin retired 20 years ago and you have enough laxity in your neck that you need a facelift, these treatments are not going to give a meaningful result in that circumstance. Likewise, if you have only minimal laxity and that little bit of tighten up is all you need and you're in your forties, likely your biological response is going to be good when we push the skin. And so a treatment like one of the non-surgical lifters can really be a great option in that circumstance, but it's important that we get appropriate patient selection because then we're most likely to get success with the non-surgical lifters.

(17:44):
There are a portion of patients who look like good candidates who have mild laxity and are in the age group that typically responds who still don't show an obvious visible change when they undergo the treatment. And that percentage is not like 1%, it's double digits. And that's frustrating because if we could tell who does respond and who doesn't respond, that would be easy, but we can't quite tell that a hundred percent. I'd like to remind the listeners there's no facelift in a bottle. We'd like there to be a simple, easy solution that gives a major change in skin laxity, but we don't have that available at this point in time. So when we think about these treatments, we want to apply the right treatment for the right patient, and we want to think about the biology, use the treatments in a biologically rational way. So again, recurrent low level treatments are going to maintain you or subtly restore you better than trying to make a big change aggressively with these energy devices because that's really not what they're designed for, and it really doesn't match how the biology works. I kind of think of it like an old horse that's tired out and you've got to get them back to the barn. Well, you don't just whip them once really hard and think they're going to run all the way home. You kick them up a little bit and they try to log for a while, and then they peter out and you kick them up again and again until you eventually work your way back to the barn.

Doreen Wu (19:29):
Exactly. It's a process. Thank you Dr. Bass for sharing your insight and expertise with us today. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you, send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.