Lifting Without Cutting #3: Ellacor w/ Dr. Jason Pozner

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. This is episode three in our series, Lifting Without Cutting, where we explore nonsurgical options for skin laxity in the face and neck. In today's episode, we are discussing Ellacor. So far in this series we've talked about energy treatments and minimally invasive procedures. What's on the agenda today?

Dr. Lawrence Bass (00:38):
Today we're talking about another local anesthesia treatment that's minimally invasive. It aims to remove a portion of the loose or lax skin in the face by micro coring the skin in a facelift or neck lift. The surgeon disconnects the skin from its underneath attachments and tailors out the excess Ellacor removes skin by punching out tiny cylinders of skin. The concept is that as these multiple small excisions heal, the total cross-sectional area of the skin is reduced. So some of that laxity or looseness is eliminated.

Doreen Wu (01:24):
That sounds like a totally different approach compared to what we've talked about before.

Dr. Lawrence Bass (01:28):
Absolutely. It's a very innovative approach. It was conceptualized originally by a dermatologist named Rox Anderson, who was the source for this concept, and Anderson is the director of the Wellman Labs of Photo Medicine at the Massachusetts General Hospital. It's a joint laboratory between Harvard Medical School and MIT. And Anderson has really been the author of many of the most innovative modern technologies in light-based therapy, energy-based treatments that we've seen over the last 30 years. This technology was recently introduced in August of 2021, so it's a little less than two years old at this point in time. And I brought an expert and a previous guest on the podcast to share his experience. He was an early adopter of the technology who now has extensive experience using it. My friend and colleague, Dr. Jason Pozner, is a board certified plastic surgeon in Boca Raton, Florida, and he has extensive experience with lasers, energy-based devices, and extensive experience with the Ellacor.

Dr. Jason Pozner (02:52):
Thanks for having me on, Larry. Thanks, Doreen.

Doreen Wu (02:54):
Welcome back. Dr. Pozner. Thank you for coming on again. So tell us a little more about what Ellacor is and how it has evolved.

Dr. Jason Pozner (03:01):
Okay, let's a couple of disclaimers first. So first of all, I did invest a little money in this company, so maybe I'm going to say some fork things that are wrong, but I doubt that. And secondly, the other inventor of this technology was Jay Austin, who is the chairman of plastic surgery at Mass General. So they're considered the co-founders of this company, both the two of them. So it's interesting you had a plastic surgeon and a dermatologist inventing this. And also disclaimer, we did two of the FDA studies for this company and also I was a reviewer first part of this study that got submitted to the FDA. So that's my disclaimers for Ellacor. We did actually, I think the first study for them, Larry, a long time ago at our office, we tattooed a one by one square on 10 patients and then we took out 10% of the skin and then a month later we measured it, the tattoo, and then we did a facelift and looked at histology and the skin shrank 10, we took out 10% and the skin shrank 10%. Pretty cool in an interesting direction pretty much this way as you would expect in the lines. And then also the histology showed nice new skin with no scar.

Dr. Lawrence Bass (04:14):
So this was an important part of how the technology had to be kind of parsed out how the playing field had to be defined before you got to clinical study in patients questions like how big a core can you take without leaving a scar? How much space has to be between them? How is it going to heal? What treatment is needed as part of the healing? Not all of these questions are a hundred percent answered before a clinical trial or even now that it's approved and on the market. But a lot was learned along the way. And it's sort of a benchmark of a lot of the Wellman Labs innovations that they're going to be very carefully scientifically researched and there's going to be a lot of outcome data in the clinical study. They're not going to be backdoored into FDA approval with a tissue heating indication or something like that. They're going to get an approval specifically for the kind of improvement they're looking to obtain.

Dr. Jason Pozner (05:27):
And interesting you mentioned that because the predicate study for this was, and Rox did a study where they did different size holes and the goal was to see, okay, what size hole leads to a scar and what size hole leads to no scar. And in general, when the hole was less than half a millimeter in diameter, there was no scar. And when the hole was bigger than half a millimeter, there was a higher incidence of scar. So that's why the Ellacor needles are just under half a millimeter. They're about the size inside diameter of a 22 gauge needle, four 20 microns, so 0.4 millimeters. So pretty cool.

Doreen Wu (06:06):
So based on our discussion so far, I think I'm starting to grasp the concept of what the treatment is trying to accomplish. Let's talk more about the process itself. Can you tell me more about how it is done, step-by-step?

Dr. Jason Pozner (06:18):
Sure. I had this done myself. So the first thing is when you're sticking needles all the way through your skin and you're doing a lot of these needles, you can imagine this is going to hurt, right? It's going to hurt. So you need to block the face. So a topical anesthetic that you might use for another procedure is not going to cut it with this. So we block the face for this. So when we've done them, and we've done quite a few at this point over 70. So if I'm doing your face and we'll talk about face to neck and face, I do nerve blocks, so infraorbital blocks, mental blocks, a little here, a little here that will block about this much. And then we put some local anesthesia infiltration in the lateral cheeks and in the neck. And then we wait about 10 minutes or so.

(07:05):
And most of the patients get, we give them Pro-Nox and sometimes a little sedative just for the needle process. That can be a little discomforting putting the needles in. But once the needles are in, you could do basically anything you want and they don't feel anything. And then we do the procedure, which is using this sort of sewing machine on the face to remove cores. And if you do a kind of a max effect on the face and neck, you'll take out with this device, 24,000 cores. That's a lot of cores in one sitting. And that takes about 25 minutes. A thousand cores a minute.

Dr. Lawrence Bass (07:38):
Wow. Okay. And I know you've had this procedure done because I've seen you doing the procedure on yourself on Instagram.

Dr. Jason Pozner (07:46):
Yeah. It was bloody, Barry called me up, one of our cook friends said, it's too bloody, take that off. And we got 3000 hits overnight. So I left it on. It was pretty good. It was no pain, no pain. And once the blocks were in, so I've had four treatments actually. So I had three done by my junior associate and one I was waiting for him and he was late, so I did it myself. I liked the one I did myself the best. Kind of weird to block your own face, but it's pretty easy to do the procedure on yourself. It didn't feel a thing. It was really numb. And then everyone wants to know, does it hurt afterwards? Nothing. Not even a Tylenol. One of the procedures, I went home, I did my Peloton, took a shower and that it went to work the next day. So it's a little messy looking the next day, but everyone seems to heal within 72 hours with very little bruising. And I mean literally I was out to dinner the next night after my first one treatment, and I worked actually after every one.

Doreen Wu (08:41):
And you kind of briefly touched on these big questions, but I'll just ask them formally. So what do you look like at the end of the treatment? What does the recovery look like and how long do you have to stay out of sight?

Dr. Jason Pozner (08:54):
So when you first finish, and I have pictures if you want to, I can send you some pictures of what I look like. I was a bloody mess when I first finished, but blood stops. So I washed my face and then five minutes later after I washed my face, I looked pink, a little red and a couple of areas, might've had a little drop of blood or so for a couple of hours. But I was good enough to go home and work out that day. Probably wouldn't want to go to dinner that night, but the next day you don't look too bad, you've had something done, you'll see some marks on your face, but you can definitely, I would say most people would stay home with the next day and not go to work unless you work in this arena and you want everybody to see what you've done. I did my significant other on a Friday night at six o'clock and she was in the gym on Sunday with makeup on at noon. So 36 hours later she was good to go. So I think between that 36 to 48 hours, you're looking pretty good.

Doreen Wu (09:52):
And what type of aftercare is needed?

Dr. Jason Pozner (09:54):
So it's interesting you ask that because in the beginning everyone was putting lots of stuff on there. And I think the problem is when you put stuff on there like creams and ointments, it gets in the holes and I think it can cause the holes not to close properly because sometimes some of the studies showed the holes closing in 10 minutes, but when I looked at it took a couple of hours when I dipped serial photos. So our current regimen, which may not be the same next week, is do nothing for two days, soap and water and a little peroxide if there's some blood after two days, mild moisturizer for five more days and then resume your normal skincare at seven days. That's our current regimen.

Dr. Lawrence Bass (10:32):
Now at one point they were talking about elastic bandage on the skin, pull the holes, close, things like that. So is that out the window at this point?

Dr. Jason Pozner (10:43):
I think if you're doing a small area like a jowl, like Suzy Kilmer test, do a little area, put a little Tegaderm on there, but if you try to do your whole face, there's no way that's going to stay on your face. There's no way on an arm. We've actually done some off face treatments with this, and we do try to directionally close them because it's easy, but there's no way that we've found, we've done a lot of work on this, but there's no way to close those holes. We actually even contemplated some elastomers that you put on your face and you heat it and it shrinks to kind of get there. But so far we haven't come up with any good way to close the holes. Now in the original study by Rox Anderson, he did directionally close the holes and he saw better closure of his holes when he used a piece of Tegaderm. And that was actually done with a laser. He used the Sciton ProFractional with a two 50 millimeter hole and did Tegaderm on it and showed directional closer. That was a predicate for this company.

Doreen Wu (11:37):
It sounds like there's some commitment to recovery there, but not a whole lot. Now I'm wondering how much improvement do you get from this procedure? What does your experience say about how much improvement is obtained and what features are addressed?

Dr. Jason Pozner (11:51):
So I think the best area you're going to see results is the jowls because I think the holes look really good on the face and the cores look really good. And we've seen the best results on the jowls. We thought the neck would be really good, but I think that the cores actually are not coming out as good on the neck. I think we're still working through some of those technical issues on how to get better cores out because we found sometimes the cores get stuck and they don't come out too much. And in that case, you just have an expensive microneedling device instead of a device that actually takes out cores. But what we found on the face is the cores are really good.

Dr. Lawrence Bass (12:29):
So the issue of features is still something I'd like to touch on a little bit because I've seen a number of before and after pictures and the intent is about treating laxity or loose skin or redundant skin. But a lot of the pictures that I've seen focus on demonstrating improvement in wrinkles and skin surface features. So what do you think it does? Is it predominantly a loose skin treatment? Is it predominantly a laxity treatment?

Dr. Jason Pozner (13:10):
Alright, in my mind, this is a skin tightening device for the FDA though it's a wrinkle reduction device because in order to get through the FDA, the FDA put them in the microneedling category and they had approved two point wrinkle reduction and that's why I was looking at a bunch of pictures as part of the FDA study to grade them. So that's why it's approved for wrinkle reduction, but it is a tightening device. That was just how the FDA mandated them to get approval.

Dr. Lawrence Bass (13:37):
Okay. I understand sometimes there's a regulatory challenge and certain groups at FDA use certain standard benchmarks to evaluate a technology that they've pigeonholed in a certain category and they feel it's only fair to hold a new technology to the same standards if it relates. But what kind of data has been generated to demonstrate laxity changes before and after treatment?

Dr. Jason Pozner (14:13):
I don't think they approach that yet. I think that that's an area that absolutely needs to be studied. I think this is sort of the time when the device hasn't really been readily available only for the last six months. Even though it was approved a year and a half ago, it was only people gotten people's hands the last six months except for a very, very select few and they just treated limited areas. So now that it's out there, I think they're accumulating data. One of the studies I'd love to see is that we've been doing Vectra photos, 3D photos on all our patients, so we'll have an idea of how much lifting we can get. And again, we've seen the best results in the jowl area as a tightening device.

Dr. Lawrence Bass (14:51):
Right. I guess in the neck it's harder to get the cores out because you don't have as firm and stable a substrate to press against like the facial muscles and bones give you a pretty firm platform to make the coring against. Is the coring largely from rotation of the needles or is it from pressure?

Dr. Jason Pozner (15:20):
Good question. No, unfortunately the answer is no. I wish they had rotation because listen, Dr. Bass and I have done a lot of biopsies. So the way you do a biopsy is you put this in the skin and you turn it, and that's how you get a core. This thing is a sewing machine. It puts a needle in and there's a little suction attached to the needle and there's also some suction around the base and then the base helps to stabilize the skin. And then the needle goes like this and there's suction in the needle. So it goes in and sucks it out. And I've tried everything on the neck like pulling as hard as I can and I just can't. Some areas, you get some good cores, but the face you get great cores, the neck, we're still working through that and I've tried various anesthesia including tumescent. It's not so easy. I think that's a challenge. I think we'll work through it and there are some alternative technologies that will be coming out that might be competitors to this that might do a better job to core through other areas.

Doreen Wu (16:13):
Another crucial question for you, Dr. Pozner. Is Ellacor a one and done treatment or do I need to do a series?

Dr. Jason Pozner (16:20):
The answer is I don't know. And currently we're selling it to patients as an individual treatment, but many of 'em are getting multiple treatments. The FDA study was two treatments. I've had four and many patients are getting a second one. And the answer is, we haven't done a good study saying how many you need. But in my mind, the more you do, the better.

Dr. Lawrence Bass (16:41):
Yeah. I think it's obviously going to be a question of stage of aging or severity of laxity. If you only have a little touch laxity, you may get enough improvement in one treatment that you're done. If you're a little bit older, you want to chase a little bit more of what's there because a little more is there and more treatments may be needed. I guess the question is, since the FDA study was two treatments, is that fundamentally how it's being marketed? And with two treatments, will the average patient get an obvious visible improvement? Because if the answer is yes, then okay, that's a fair representation. But if you improve but you don't really see it until you do a bunch more, then you start to feel like it has to be represented more like a series. But it sounds like the data clearly showed improvement with the two treatments in the FDA study

Dr. Jason Pozner (17:47):
For wrinkles and those patients are older. I mean, I look at this as a treatment where you might have a younger patient in their forties and you do this once a year and maybe by the time you get to your fifties you don't ever need a facelift because you're progressively tightening over time. I mean, that's the holy grail that Dr. Bass and I have talked about for a hundred years. The holy grail of plastic surgery is non-surgical tightening, and this is the next latest greatest step towards that. I don't think we can take an older patient that needs a facelift and give them a facelift result yet maybe soon, but not yet.

Dr. Lawrence Bass (18:21):
Yeah, and there's another component here. It is multifactorial what features you're addressing. And a lot of treatments we do are like that. So for example, when we did laser resurfacing in the old days, the big CO2 laser peels in the mid 1990s, well people's skin would always be a little bit tighter and their wrinkles would be nicely erased. So while you're getting your wrinkles erased, you're always happy if you get a little tightening, sure you'll take it. I never thought that was a good reason to do a laser peel solely for the tightening, but we're happy to get that added benefit. So I guess my question about Ellacor is the improvement mostly about wrinkles where we have all kinds of options to chase it depending on severity, is it mostly about laxity improvement? What's the mix?

Dr. Jason Pozner (19:21):
I mean, I don't sell this for wrinkles. I think we have far better wrinkle technology. I would rather burn your face off with a laser with an Erbium laser and get a consistent result. I mean, Dr. Bass, we've done thousands of these over our lifetimes. We know we can get a result.

Dr. Lawrence Bass (19:36):
I think you meant to say you would rather precisely ablate a very controlled portion of surface epidermis and dermis in the quest of facing wrinkles in your patients.

Dr. Jason Pozner (19:50):
The older I get, the blunter I get, I tell 'em on the laser patients, you'll be great for Halloween for a couple of days. And you know what? The blunter I am the more they appreciate it. That's how, it's interesting. We're getting old. It doesn't matter what we say.

Dr. Lawrence Bass (20:05):
No, I think it matters. But I think patients appreciate being told the real deal and hearing things in a forthright way. There's so much hype and so much noise in the aesthetic marketplace that hearing a little dose of the truth is really a good thing.

Dr. Jason Pozner (20:22):
I agree. And we joke around with that, but our precision lasers that ablate dermis and epidermis and can create a controlled second degree burn. We've done these for 20 something years. We can get predictable, beautiful results, and basically we're burning your face off for a couple of days and it heals beautifully. But those things get rid of wrinkles. I don't consider them the tightening agents. This is a tightening agent. That's how I would sell it to the patient. I sell it as a tightening agent. And remember, there's another patient that had a facelift and you had a facelift in the past, and you're a little older now, and maybe you're a little lax because facelifts don't stay tight forever. And unless we make them look like the joker right away and nobody wants to look like the joker. So these areas, especially the jowls, tend to relax a little bit. So that's a great thing to do on a post facelift patient is to do a little Ellacor on them. They tighten up very nicely for that and they won't need a second facelift.

Doreen Wu (21:17):
And who else would you say is an ideal candidate for this procedure?

Dr. Jason Pozner (21:21):
I think young patients looking to improve their laxity. Bald plastic surgeons who can't hide facelift scars are also good candidates, really anyone. But I think to the older patient who's 90 years old with a lot of laxity, I always think of lasers and other energy devices as I do my part and the patient has to do their part. Even though you're taking out some of their skin, I think some of the older patients can't do their part to heal properly, so they may not tighten as much as someone who's Doreen's age.

Doreen Wu (21:53):
And lastly, as we wrap up Dr. Pozner, what takeaways would you leave our listeners with if you bottom line it for me, what should they know about Ellacor versus other nonsurgical alternatives?

Dr. Jason Pozner (22:03):
I think Ellacor is probably the best of the non-surgical tightening devices in 2023 that we have. But there's a little bit of downtime and there's a little pain from the needles. And if you're looking for a lunchtime procedure that you can go out to have a martini right away, that's not it. But if you don't mind staying home for 36 hours, you will get a great result. I still think this is the best bet for 2023 for non-surgical tightening.

Doreen Wu (22:27):
And Dr. Bass, would you like to add any takeaways?

Dr. Lawrence Bass (22:29):
So as we mentioned, this technology and Dr. Pozner pointed out, even though we're close to two years since it's been FDA approved, it hasn't been widely available until six months ago. So we're really learning about indications, a lot of data being accumulated about outcomes and what treatment techniques get patients through this as quickly and easily as possible. So this will continue to refine as we learn about this technology and as the technology evolves, it's a great option for patients with the right indication and the right stage of aging. So like everything in plastic surgery and aesthetic medicine, if you use it for what it's good for and don't force it to try to do what it's not really designed to do, you tend to get the advertised results. We're still waiting on how to do the neck maybe a little bit better and looking at specific outcome data about laxity because the current indication is for treatment of moderate to severe wrinkles in the mid to lower face. So I'd like to thank Dr. Pozner for joining us again. As always, his experience and his ability to be very well-informed about the latest in technology and to share with us in an entertaining way continues to be unparalleled. So Jason, thank you.

Doreen Wu (24:10):
Thank you Dr. Pozner for joining us today and sharing your cutting edge firsthand experience with Ellacor. 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.