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

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Welcome to Park Avenue
Plastic Surgery Class,

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a podcast where we explore controversies
and breaking issues in plastic surgery.

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I'm your co-host Doreen Wu,

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a clinical assistant at Bass
Plastic Surgery in New York City.

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I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,

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educator and technology innovator.

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The title of today's episode is
Lift, But Don't Cut. All right,

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Dr. Bass, you've piqued
my curiosity yet again.

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What are we talking about in this episode?

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Well, Doreen, this episode is about
the technologies available for

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non-surgical lifting and about the biology

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behind that process.

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It's also about where we stand with
these technologies and how to think about

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the best ways to use them because that's
really critically important to success

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when it comes to non-surgical lifting.

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I've often said from the lecture podium
that this is the holy grail of plastic

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surgery, the ability to lift the
face and neck skin without surgery.

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That's something most of
us would be interested in,

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a far larger group than those who
are actually undergoing the facelift

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surgery itself.

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Where do these technologies for
non-surgical lifting come from?

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I'm ready for my history lesson.

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We saw flickers of skin tightening

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possibilities from various
skin smoothing treatments,

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things that were designed
to treat wrinkles,

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so things like chemical
peels and laser peels.

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We would notice if you did a
pretty deep aggressive peel in

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addition to smoothing out or
ironing out some of the wrinkles,

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the skin would be modestly tighter.

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So that piqued everyone's curiosity
and got them interested in

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looking at how to make that into
a treatment in and of itself.

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In the 1990s,

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there were multiple attempts using
lasers and other infrared light

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sources to create a controlled thermal

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injury in the skin that would
then heal with tighter lifted

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skin.

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During this time period in the 1990s,

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did any devices come
out for skin tightening?

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Well, not per se.

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There were some attempts using
neodymium YAG lasers and infrared light

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sources, but the approvals from FDA,

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or clearances,

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were always for tissue heating or tissue

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coagulation because the manufacturers

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basically showed that they were equivalent
to antecedent devices in terms of

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their ability to create tissue heating,

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and that allowed them to get on the
market while avoiding the need to

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prove the safety and efficacy of

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skin lifting.

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And FDA has an issue with the notion

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of tightening. We talk about
tightening all the time.

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The FDA has an issue with this

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nomenclature of tightening versus lifting.

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So we talk about tightening all the time,
plastic surgeons and their patients.

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People understand when their skin is
tight and when their skin is loose and

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saggy. But to FDA,

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the ability to create a
scientific definition and proof

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for tightening the skin has not been
something they've been able to sort

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out. They have permitted
the use of the term lifting

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because that takes skin that's sitting
in one position and moves it to a

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different position,

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and that can be measured and proven.

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And so FDA in more
recent years has provided

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lifting clearances for
a number of devices,

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and I think part of the confusion comes
out of the issue of thinking about skin

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and they're trying to understand
how can you tighten skin,

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but skin is not really static like
a piece of cloth. It's dynamic.

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It has elastic response both
in the short term and for

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long-term stress effects.
So if you pull on your skin,

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it stretches a little and
expands and then it shrinks back.

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If you stretch it long-term like with
pregnancy or plastic surgeons who use

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tissue expanders that are temporary

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saline bags that are
placed under the skin,

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slowly blown up to create extra skin for

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reconstructive plastic surgery,

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we know that skin can stretch quite a
bit if it's put on sustained stretch

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over weeks and months.

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So when did the modern era of
non-invasive skin treatments really begin?

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This was in the early two
thousands with two events.

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One was the introduction of
a device called Thermage,

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and another was the, at
just about the same time,

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the first introduction of
fractional energy-based

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treatments.

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So Thermage basically
started as a single depth

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radiofrequency treatment.

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A handpiece was held against the skin
radiofrequency energy was put in to

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create a controlled thermal injury at

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the deep edge of the skin.

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And this got approvals for things
like crow's feet in the lateral

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eyelid area, but also to lift the brow

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and elevated from its baseline position,

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and then fractional treatments
or treatments that instead
of exposing the entire

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area,

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expose only a portion of the skin
broken up into small shapes like

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pin dots with skip areas in between,

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which allows you to create different
effects in the skin than what might be

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tolerated or what might heal. Well,

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if it was a full field treatment.

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Where did it go from there?

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So the next lifting devices,

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which actually ended up with
actual lifting clearances from

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FDA,

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were Ultherapy and more recently Sofwave.

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So Ultherapy is a fractionated
ultrasound treatment

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that creates multiple dots of thermal

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injury at defined depths under the skin.

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So it's fractionated and it's multi depth

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or multilayer in its treatment. Sofwave,

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which has become available more recently,

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also uses sound energy and creates
fractionated exposures at a

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single depth under the skin, but
covering a greater cross-sectional area.

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So far, all of the treatments we've
talked about are non-invasive,

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which is good for people who
aren't ready to undergo surgery.

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But you mentioned it can be difficult
to amplify the effect using these

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treatments. Can you
talk about why that is?

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Well,

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the issue is the degree
of laxity that somebody

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has and what data these devices have

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available.

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The data is produced in a certain
population of patients with a certain age

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range, a certain degree of laxity,

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and you can't necessarily
crossly that to other types of

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patients.

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It's also about some of the biology

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and how the body responds
to the energy exposures that

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are involved. So as I said,

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each of these technologies creates
a controlled thermal injury.

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The body recognizes that the tissues
have been heated up and in some way

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damaged and it initiates
a healing response.

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That healing response
creates new collagen,

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and the new collagen, like thousands
of tiny guidelines under the skin

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creates lifting by pulling
the skin tighter, smoother,

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and lifted.

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And it's partly a product
of what depth it's done at.

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It's partly a product of how
much of that response you

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can stimulate.

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Speaking of biology, let's talk
about how these technologies work.

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Can you break it down for me?

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So this is really important.
It is about the biology.

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It's about the biology of
how our skin changes as we

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age.

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It's also about the biology of
how our skin responds when it's

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pushed with these
controlled thermal injuries.

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So I call this the Thermage lesson
because it really came out of

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some of the early
experience with Thermage.

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Number of people using the device
we're trying to amplify the response.

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So they said, well, if a little
energy is good, more must be better.

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And at that time, the
treatment was a single pass

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and a single treatment.

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So that means each area of skin that
you were trying to lift would be touched

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with the handpiece once and
have an energy exposure.

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And at the end of one treatment,

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you were hoping the patient would go
home and the body would add new collagen

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for a few months and lift them.

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And what happened when people tried
to turn up the energy to get more

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response was the complication rate went up

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significantly.

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But the biological response in terms
of lifting was really not much better,

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incrementally better, but not much.

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So the lesson was more complications not

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acceptable, especially
for a cosmetic treatment.

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So a number of people with experience
with the technology met with the

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company, put their heads together,

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and they figured out that dialing down the

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energy

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but doing multiple passes going over
the skin more than once was much

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safer, but it pushed the response harder,

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and then they likewise considered
circling back in six weeks

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and doing a second treatment.

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This actually improved the clinical
response and took the complications almost

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to zero.

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So that's a very important lesson
about biology and what it means

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is you can, at a certain
threshold of injury,

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you can turn the response on,

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but you can't amplify it by adding
more energy or going to a higher

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temperature. It's like
flipping a light switch.

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If you push on the switch but not hard
enough, the light's going to stay off.

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And once you push it hard
enough to flip it up,

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the light's going to go on and flipping
it up harder or faster doesn't make the

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light anymore on, and unfortunately,

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the biology of this
kind of skin remodeling,

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that's how it works.

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The other thing I said
is biology as we age and

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remodeling is something we're doing
actively all the time with our skin.

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We do it faster and more
effectively when we're younger,

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we do it slowly or more
slowly and less accurately and

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less completely when we're older.

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So we can't turn back on
the full response we had,

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let's say at 20 years
old, and even if we did,

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it wouldn't stay on for long.

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We need to keep repeating
the stimulus of the energy

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treatment to keep the response on. Also,

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the stimulus has to be working for a
long time to make a big change. Remember,

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we lost our remodeling and
then got saggier and saggier

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over decades,

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and this isn't going to fully
reverse even in a few months.

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So with this slower skin biology,

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the rational way to do these treatments
is to push the skin periodically

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over and over, not just
push it once really hard.

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So it's like that Thermage lesson.

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We learn multiple passes at low energy
or better than one pass at high energy.

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Multiple treatments over time,

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periodically are going to be better than
just one really aggressive treatment.

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The problem is this doesn't really match
the business model of the devices or

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how they're being used in the
United States. This is again,

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the business decisions of the companies
and it's the temperaments of the

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doctors and the patients. I'm
a New Yorker, we're impatient,

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we're busy, we want it fixed
and get on with things.

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But unfortunately, that's not how it's
going to work with non-surgical lifting

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until we really find a different
approach for non-surgical lifting.

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I believe it's best done as a process
and other countries in the world

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take much more of that approach
when they use these devices and have

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had actually often impressive

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levels of success with it.

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Are there alternatives to a full open
surgery like a facelift or a neck lift,

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something that will
provide comparable results?

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So we've been talking about
applying the energy externally,

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but you can also apply energy under the
skin in a minimally invasive fashion.

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So devices like FaceTite,

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which uses radio frequency energy
in a minimally invasive fashion

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are able to place a great deal
of energy right under the skin,

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right where you need it in a safe fashion.

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You don't have to get it through the
skin safely because you're delivering it

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directly where you need it,

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and that might be a next step up depending
on the degree of laxity that you're

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showing, showing where the degree
of response you're hoping to get.

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After our discussion today of all these
different non-surgical lifting options,

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in your opinion, Dr. Bass, is
the facelift outmoded? If not,

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why isn't it?

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So as I said previously,

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there's really no substitute currently or

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on the horizon that can give the degree of

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laxity correction for people with
significant laxity in the jowl,

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jawline, or neck areas.

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Facelift is really the
big facial reset and has

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the ability to make a major change
in one step with a great deal of

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durability a decade or longer typically.

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So there's nothing else we have that
can do that for people that have already

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reached that point in the aging continuum,

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they're still looking at a facelift,
but for people who are not there yet,

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they still have the option
to pursue a more limited

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alternative like what we've
been discussing in this episode.

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Lastly, Dr. Bass,

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can you give our listeners some
parting takeaways from this episode?

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So all of these treatments are extremely
useful and it's great to have them

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available,

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but they only give you what you are
hoping for if you are a good candidate for

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that treatment.

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So if you are 80 years old
and pushing your skin with

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energy is not going to get much
biological response because your skin

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retired 20 years ago and you have

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enough laxity in your neck
that you need a facelift,

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these treatments are not going to give a
meaningful result in that circumstance.

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Likewise,

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if you have only minimal laxity and that

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little bit of tighten up is all you
need and you're in your forties,

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likely your biological response is
going to be good when we push the skin.

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And so a treatment like one of the
non-surgical lifters can really be a

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great option in that circumstance,

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but it's important that we get appropriate

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patient selection because
then we're most likely to get

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success with the non-surgical lifters.

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There are a portion of patients who
look like good candidates who have mild

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laxity and are in the age
group that typically responds

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who still don't show an obvious visible
change when they undergo the treatment.

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And that percentage is not
like 1%, it's double digits.

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And that's frustrating because if we could
tell who does respond and who doesn't

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respond, that would be easy,

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but we can't quite tell
that a hundred percent.

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I'd like to remind the listeners
there's no facelift in a bottle.

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We'd like there to be a simple,

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easy solution that gives a
major change in skin laxity,

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but we don't have that
available at this point in time.

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So when we think about these treatments,

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we want to apply the right
treatment for the right patient,

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and we want to think about the biology,

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use the treatments in a
biologically rational way. So again,

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recurrent low level treatments are
going to maintain you or subtly restore

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you better than trying to make a
big change aggressively with these

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energy devices because that's really
not what they're designed for,

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and it really doesn't match
how the biology works.

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I kind of think of it like an old
horse that's tired out and you've got

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to get them back to the barn. Well,

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you don't just whip them once really hard
and think they're going to run all the

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way home. You kick them up a little
bit and they try to log for a while,

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and then they peter out and you kick
them up again and again until you

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eventually work your way back to the barn.

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Exactly. It's a process.

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Thank you Dr. Bass for sharing your
insight and expertise with us today.

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Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.

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write a review and share
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00:19:43,500 --> 00:19:46,590
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send us an email at podcast@drbass.net
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