Lifting Without Cutting #6: Overview of Series

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. Today's episode is the final in our series Lifting Without Cutting. This is episode six where we recap what we've learned so far. What are you planning for us today, Dr. Bass?

Dr. Lawrence Bass (00:31):
We've heard about a number of very different types of options over the course of this series. Today I'd like to try to summarize what we found and how to choose between these options. So let's review what we've covered. In episode one, we talked about some of the historical approaches to skin remodeling using skin heating and what the biology is of, how the healing response occurs and how these technologies work. And there were some important lessons there to remember as we look at some of the more recent additions that are variations or improvements on pursuing those strategies. In episode number two, we went in a very different direction. We looked at MyEllevate, which is a local anesthesia procedure that's done only with needle punctures, no incisions, and it's focused on improving early laxity in the neck and jawline. In episode three, we looked at Ellacor, which is a micro coring technology, a technology where little circles of skin are punched out for skin area reduction. And this is focused on the face, although it's also done on the neck. In episode four, we looked at FaceTite and AccuTite, and this is minimally invasive through small needle puncture in the skin where the energy is introduced radiofrequency under the skin to stimulate tissue remodeling. And this is for skin laxity before surgery is needed done at the same time as surgery or after things like facelift for maintenance. And in episode five, we looked at Sofwave. This is the latest advance in wholly non-invasive lifting, ideal for early laxity treatments.

Doreen Wu (02:41):
That helped jog my memory, and that was a nice episode recap, and I even noticed that you snuck in a few key takeaways for each episode. How else can you organize what we've looked at in this series?

Dr. Lawrence Bass (02:53):
So there are very different categories to these technologies. Some use transcutaneous energy, energy that comes from outside, passes through the skin and has its effect that way. These are fully noninvasive energy put through intact skin, and this can be fractionated or it can be full field. And there's a history to this with light-based systems. There are radio frequency wanding systems and other kinds of RF systems like Thermage and some things that use sound energy like ultrasound that's therapeutic rather than diagnostic. There are intracutaneous treatments or ones that go immediately subdermal under the skin like radiofrequency microneedling. And then there's subcutaneous energy procedures, ThermiRF, and more recently in mode facet tight acuate that are minimally invasive, have a little drop of bruising, swelling, recovery, but pass energy under the skin and can put much more energy at the target area than transcutaneous approaches. And then there are needle puncture procedures, actual little procedure interventions like thread lifts and procedures like MyEllevate.

Doreen Wu (04:19):
What did the series tell us about the current status of non-surgical skin lifting?

Dr. Lawrence Bass (04:24):
Well, the way I like to think of it is there's this succession of options depending on the stage of aging and the location of the findings. So some procedures are better for the neck, like MyEllevate. Some are better for the face like Ellacor, and you start with things that are wholly non-invasive and you eventually move to minimally invasive options.

Doreen Wu (04:49):
What are some of the other differences?

Dr. Lawrence Bass (04:52):
So they're starting to be not just energy treatments, but these procedural options that don't just put energy in the skin and count on skin remodeling because we discussed that there are a number of biological limitations of this. For early laxity, we can definitely get skin to remodel. You're still reasonably young, the skin is reasonably responsive and you don't need much improvement, but we have trouble amplifying that response as people age and experience in the increasing amount of laxity. The trend is also in a couple of other areas. Some of these things are just done with no anesthesia, like Sofwave or some of the older radio radiofrequency wanding treatments that are all relatively comfortable. Some require local anesthesia to completely numb the area where the treatment's not tolerated. And so that's a difference in terms of what the experience of the treatment is like. There are also some differences in how much recovery is involved.

Doreen Wu (06:06):
Where does that ultimately leave us? What is the role of these options?

Dr. Lawrence Bass (06:11):
So as I said, it depends on the stage of aging. Nothing replaces surgical facelift or neck lifting. There's no meaningful substitute currently, and there's none on the horizon. So if you're squarely in facelift territory, fortunately facelift is faster, easier, more reliable and it's ever been. But that's really the only answer that's going to give you meaningful progress. But there's a role for these treatments before it's time for a facelift, both to prevent the advancement of aging or slow the advancement because we can't stop it and to restore some of the early changes and then to maintain that restoration also after facelift to help maintain the restoration and get the greatest degree of mileage out of the facelift.

(07:12):
Basically, people who are candidates for this don't have obvious hanging skin and they're not very aged at the upper extreme of age because the biological response of the skin is blunted. So if you're in one of those two categories, these lifting without cutting technologies are not appropriate for you. But if you're short of that, you can get benefit from them. You still have to be realistic about how much improvement these treatments will provide. The treatment is not going to give you a facelift like result with any of these treatments. It's not what we expect and it's not what they're capable of doing. If that's your expectation, you're bound to be disappointed. But if you can live with a smaller degree of improvement and find that beneficial, restores your confidence, gives you the look you need to be comfortable in public, then these are excellent options.

Doreen Wu (08:15):
I'm going to raise an issue that we've discussed before as well. Should treatments be single or multiple like in a series?

Dr. Lawrence Bass (08:23):
So first we have to distinguish treatments that are represented to be a series compared to those that are intended as a single treatment. So RF wanding treatments, microneedling treatments with radio frequency. Those are always meant to be a series, typically five or six treatments for many of those devices. So you're signing up for a series if you do one of those. And predictably, if you do one or two treatments, you don't really get a lot of meaningful progress. Other treatments like Ultheraoy, Sofwave, FaceTite, these are designed to be single treatments. Some people do a second treatment, but the intent is to have an obvious visible improvement after a single treatment. And this issue really relates to procedures that provide energy and stimulate the skin to respond. Procedures like threads and MyEllevate, they're obviously one treatment. They're designed to reposition things to the extent that they're able to, but the energy treatments, we're pushing the skin, we're trying to get a response, but again, we have to keep reminding the skin to act in a youthful fashion. We're accumulating a lot of very tiny amounts of improvement over a large area. A lot of people will say, well, I just need it here, but no, we want to do it over a large area. Cumulate all that tighten up over as big an area as we can so it adds up to a meaningful change in the problem area.

Doreen Wu (10:09):
And what about the issue of non-responders? What are they? Why does it happen?

Dr. Lawrence Bass (10:15):
So a non-responder doesn't mean that nothing happened because if we took a biopsy of your skin after delivering the energy, we'd probably find that you made some new collagen. And the tissues may be thicker, they may be a little more youthful in various ways, but not enough that you see any difference on the outside. And since this is about your appearance, if we don't see a difference, that's essentially a treatment failure, what we call a non-responder. So that's the definition to start with. I always have a suspicion about treatments that put energy into the skin to stimulate the skin, to add collagen or tighten or remodel in some way and say that everyone responds because that doesn't intrinsically match the biology of the process. Even when you take ideal candidates, and this is one of the frustrations with these treatments, when you take people in their forties who have good quality skin and early aging changes, a portion will typically be non-responders.

(11:27):
And unfortunately, you can't look at people ahead of time and tell who we know that at the extremes of age, as you get into seventies, eighties and beyond, the likelihood your skin is going to make meaningful remodeling changes really diminishes. And that's not a big surprise. But the frustration is that even in the ideal candidates who are young, there's some benefit because you've probably maintained in some way, but you just can't see a difference. And how we overcome that has been a challenge. Usually increasing the amount of energy or retreating does not turn a non-responder into a responder, although sometimes that can happen. And with some of the newer technologies, there's been some reporting that maybe that's taking place, but it's probably something that we're going to have to look to biological or regenerative approaches to make you more susceptible to respond when you're stimulated by the energy.

Doreen Wu (12:46):
Now Dr. Bass, how do you think this will play out going forward?

Dr. Lawrence Bass (12:50):
So we've seen regenerative approaches amplifying our biological processes, turning back on youthful behaviors in the skin start to come into play as a primary therapy for skin aging, but also mated with energy treatments to prime the skin to behave with a youthful response and then trigger that response using energy. And as part of the healing from that energy based treatment, you are now much better able to achieve the goals of that treatment. And I think those kind of mated therapies are going to be central to our approach going forward.

Doreen Wu (13:39):
This is the summary episode for the Lifting Without Cutting series. So the takeaways are the most important part. You can go ahead and share them with us now.

Dr. Lawrence Bass (13:47):
So these treatments have an important role for a very large group of patients. Basically everybody who's got some aging changes but not enough to warrant a facelift or a neck lift. Still, it's not a magic substitute for the facelift or neck lift. And people with obvious hanging skin and redundancy, more than just mild laxity are not really going to benefit from most of these treatments or are only going to benefit if it's done in conjunction with surgical lifting. In surgical face and neck lifting, we're doing a bunch of other things to deal with the foundation in the face, the deeper level tissues to adjust shape and position of structures in the face, not just to take out a little bit of the extra skin. So both for the amount of skin that we can tailor and the other changes we're not really substituting for the face or neck lift.

(14:58):
There are some areas facelift or neck lift doesn't fully correct or doesn't address the upper area of the jowl, a little bit of residual skin in the angle of the neck, the nasolabial and marionette areas. And these are areas where in conjunction with facelifting, we can get those remaining areas that facelifting is not doing what we want in terms of picking which technology is appropriate. I always think ones with an FDA indication for lifting have been able to provide evidence to FDA, so they're preferable than other technologies that are just trying to backhand onto that indication without generating clinical data. Even so, some may not have an FDA indication, but they have done some clinical studies. I think clinical data having outcomes is critically important to understanding what the technologies can do for you. That way you know that there's something believable, that it's not a fantasy or that make believe world of no non-responders, which I don't believe exists sometimes the number of non-responders is significant.

(16:23):
And it's important to understand that before you pick a given treatment, because we'd like to repeat these treatments, not necessarily do them in a series, but keep stimulating the skin over time. Circle back in six months, a year or two years, three years, and push the skin again. It's easier to do treatments that don't have a high disposable cost. It's easier to do treatments that have no recovery and that are non-invasive, but sometimes depending on stage of aging, it's better to pick something that has some of those downsides associated with it, but is going to give you a more meaningful result. Using these technologies can greatly delay the need for the full surgical facelift and neck lift, and that's a paradigm shift. If you treat early and often, you won't need to use the big option, the facelift and neck lift until much later.

Doreen Wu (17:22):
Thank you Dr. Bass for sharing your expertise and bringing this series to such a well thought out close. 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.