Lifting Without Cutting #6: Overview of Series

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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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Today's episode is the final in
our series Lifting Without Cutting.

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This is episode six where we
recap what we've learned so far.

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What are you planning
for us today, Dr. Bass?

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We've heard about a number
of very different types of
options over the course of

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this series.

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Today I'd like to try to summarize
what we found and how to choose

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between these options. So let's
review what we've covered.

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In episode one,

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we talked about some of the
historical approaches to skin

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remodeling using skin heating and what the

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biology is of,

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how the healing response occurs
and how these technologies work.

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And there were some important lessons
there to remember as we look at some of

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the more recent additions
that are variations or

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improvements on pursuing those strategies.

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In episode number two, we went
in a very different direction.

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We looked at MyEllevate,

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which is a local anesthesia procedure
that's done only with needle

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punctures, no incisions,

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and it's focused on improving
early laxity in the neck and

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jawline. In episode three,

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we looked at Ellacor,

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which is a micro coring technology,

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a technology where little
circles of skin are punched out

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for skin area reduction. And
this is focused on the face,

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although it's also done on
the neck. In episode four,

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we looked at FaceTite and AccuTite,

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and this is minimally invasive through

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small needle puncture in
the skin where the energy is

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introduced radiofrequency
under the skin to stimulate

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tissue remodeling.

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And this is for skin laxity before
surgery is needed done at the

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same time as surgery or after things
like facelift for maintenance.

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And in episode five, we looked at Sofwave.

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This is the latest advance in
wholly non-invasive lifting,

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ideal for early laxity treatments.

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That helped jog my memory, and
that was a nice episode recap,

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and I even noticed that you snuck in
a few key takeaways for each episode.

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How else can you organize what
we've looked at in this series?

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So there are very different
categories to these technologies.

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Some use transcutaneous energy,

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energy that comes from outside,

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passes through the skin and
has its effect that way.

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These are fully noninvasive
energy put through intact

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skin, and this can be fractionated
or it can be full field.

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And there's a history to this
with light-based systems.

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There are radio frequency wanding
systems and other kinds of RF

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systems like Thermage

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and some things that use sound energy

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like ultrasound that's therapeutic
rather than diagnostic.

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There are intracutaneous treatments or
ones that go immediately subdermal under

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the skin like radiofrequency
microneedling.

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And then there's subcutaneous
energy procedures, ThermiRF,

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and more recently in mode
facet tight acuate that are

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minimally invasive, have a little
drop of bruising, swelling, recovery,

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but pass energy under the skin and
can put much more energy at the

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target area than
transcutaneous approaches.

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And then there are needle
puncture procedures,

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actual little procedure
interventions like thread lifts

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and procedures like MyEllevate.

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What did the series tell us about the
current status of non-surgical skin

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lifting?

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Well,

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the way I like to think of it is there's
this succession of options depending on

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the stage of aging and the
location of the findings.

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So some procedures are better
for the neck, like MyEllevate.

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Some are better for the face like Ellacor,

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and you start with things that are
wholly non-invasive and you eventually

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move to minimally invasive options.

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What are some of the other differences?

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So they're starting to be
not just energy treatments,

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but these procedural options that don't

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just put energy in the skin and
count on skin remodeling because we

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discussed that there are a number
of biological limitations of this.

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For early laxity, we can
definitely get skin to remodel.

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You're still reasonably young,

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the skin is reasonably responsive
and you don't need much

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improvement,

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but we have trouble amplifying
that response as people

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age and experience in the
increasing amount of laxity.

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The trend is also in a
couple of other areas.

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Some of these things are
just done with no anesthesia,

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like Sofwave or some of the older radio
radiofrequency wanding treatments that

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are all relatively comfortable.

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Some require local anesthesia
to completely numb the

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area where the treatment's not tolerated.

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And so that's a difference in terms of
what the experience of the treatment is

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like. There are also some differences
in how much recovery is involved.

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Where does that ultimately leave us?
What is the role of these options?

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So as I said, it depends
on the stage of aging.

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Nothing replaces surgical
facelift or neck lifting.

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There's no meaningful
substitute currently, and
there's none on the horizon.

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So if you're squarely
in facelift territory,

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fortunately facelift is faster, easier,
more reliable and it's ever been.

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But that's really the only answer
that's going to give you meaningful

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progress. But

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there's a role for these treatments
before it's time for a facelift,

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both to prevent

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the advancement of aging or slow the
advancement because we can't stop it

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and to restore some of the early
changes and then to maintain

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that restoration also
after facelift to help

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maintain the restoration and get the
greatest degree of mileage out of the

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facelift. Basically,

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people who are candidates for this
don't have obvious hanging skin

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and they're not very aged
at the upper extreme of age

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because the biological response
of the skin is blunted.

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So if you're in one of
those two categories,

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these lifting without cutting
technologies are not appropriate for you.

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But if you're short of that,
you can get benefit from them.

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You still have to be realistic about how
much improvement these treatments will

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provide.

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The treatment is not going to give you
a facelift like result with any of these

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treatments. It's not what we expect and
it's not what they're capable of doing.

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If that's your expectation,
you're bound to be disappointed.

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But if you can live with a
smaller degree of improvement

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and find that beneficial,
restores your confidence,

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gives you the look you need
to be comfortable in public,

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then these are excellent options.

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I'm going to raise an issue that
we've discussed before as well.

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Should treatments be single
or multiple like in a series?

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So first we have to distinguish treatments
that are represented to be a series

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compared to those that are
intended as a single treatment.

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So RF wanding treatments,

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microneedling treatments
with radio frequency.

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Those are always meant to be a series,

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typically five or six treatments
for many of those devices.

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So you're signing up for a
series if you do one of those.

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And predictably, if you
do one or two treatments,

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you don't really get a lot
of meaningful progress.

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Other treatments like
Ultheraoy, Sofwave, FaceTite,

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these are designed to
be single treatments.

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Some people do a second treatment,

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but the intent is to have an
obvious visible improvement after a

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single treatment.

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And this issue really
relates to procedures that

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provide energy and stimulate
the skin to respond.

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Procedures like threads and MyEllevate,

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they're obviously one treatment.

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They're designed to reposition things
to the extent that they're able to,

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but the energy treatments,
we're pushing the skin,

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we're trying to get a response, but again,

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we have to keep reminding the
skin to act in a youthful fashion.

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We're accumulating a lot of
very tiny amounts of improvement

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over a large area. A lot of people
will say, well, I just need it here,

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but no, we want to do
it over a large area.

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Cumulate all that tighten
up over as big an area as we

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can so it adds up to a meaningful
change in the problem area.

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And what about the issue of
non-responders? What are they?

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Why does it happen?

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So a non-responder doesn't mean that
nothing happened because if we took a

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biopsy of your skin after
delivering the energy,

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we'd probably find that
you made some new collagen.

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And the tissues may be thicker,

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they may be a little more
youthful in various ways,

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but not enough that you see
any difference on the outside.

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And since this is about your appearance,
if we don't see a difference,

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that's essentially a treatment
failure, what we call a non-responder.

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So that's the definition to start with.

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I always have a suspicion
about treatments that put

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energy into the skin
to stimulate the skin,

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to add collagen or tighten
or remodel in some way

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and say that everyone responds

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because that doesn't intrinsically
match the biology of the

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process. Even when you
take ideal candidates,

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and this is one of the
frustrations with these treatments,

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when you take people in their forties
who have good quality skin and early

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aging changes,

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a portion will typically
be non-responders. And

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unfortunately,

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you can't look at people ahead of
time and tell who we know that at the

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extremes of age, as you get into
seventies, eighties and beyond,

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the likelihood your skin is going
to make meaningful remodeling

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changes really diminishes.

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And that's not a big surprise.

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But the frustration is that even in
the ideal candidates who are young,

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there's some benefit
because you've probably

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maintained in some way, but you
just can't see a difference.

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And how we overcome that has been a

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challenge.

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Usually increasing the amount of energy or

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retreating does not turn a
non-responder into a responder,

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although sometimes that can happen. And
with some of the newer technologies,

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there's been some reporting
that maybe that's taking place,

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but it's probably something that
we're going to have to look to

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biological or regenerative
approaches to make you

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more susceptible to respond when
you're stimulated by the energy.

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Now Dr. Bass, how do you think
this will play out going forward?

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So we've seen regenerative
approaches amplifying our

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biological processes,

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turning back on youthful
behaviors in the skin

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start to come into play as a primary

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therapy for skin aging,

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but also mated with energy
treatments to prime the

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skin to behave with a youthful response

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and then trigger that
response using energy.

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And as part of the healing from
that energy based treatment,

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you are now much better able to
achieve the goals of that treatment.

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And I think those kind of
mated therapies are going to be

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central to our approach going forward.

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This is the summary episode for
the Lifting Without Cutting series.

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So the takeaways are
the most important part.

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You can go ahead and
share them with us now.

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So these treatments have
an important role for a

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very large group of patients.

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Basically everybody who's got some
aging changes but not enough to

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warrant a facelift or a neck lift. Still,

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it's not a magic substitute
for the facelift or neck lift.

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And people with obvious
hanging skin and redundancy,

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more than just mild laxity

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are not really going to benefit
from most of these treatments or are

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only going to benefit if it's done
in conjunction with surgical lifting.

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In surgical face and neck lifting,

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we're doing a bunch of other things
to deal with the foundation in

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the face, the deeper level tissues
to adjust shape and position of

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structures in the face,

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not just to take out a
little bit of the extra skin.

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So both for the amount of skin
that we can tailor and the

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other changes we're not really
substituting for the face or neck lift.

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There are some areas facelift or neck
lift doesn't fully correct or doesn't

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address the upper area of the jowl, a

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little bit of residual skin
in the angle of the neck,

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the nasolabial and marionette areas.

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And these are areas where in
conjunction with facelifting,

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we can get those remaining areas that

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facelifting is not doing
what we want in terms of

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picking which technology is appropriate.

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I always think ones with an FDA
indication for lifting have been able to

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provide evidence to FDA,

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so they're preferable than
other technologies that are just

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trying to backhand onto that
indication without generating clinical

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data. Even so, some may
not have an FDA indication,

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but they have done some clinical studies.

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I think clinical data having
outcomes is critically important

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to understanding what the
technologies can do for you.

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That way you know that
there's something believable,

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that it's not a fantasy or that make

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believe world of no non-responders,

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which I don't believe exists
sometimes the number of

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non-responders is significant. And it's
important to understand that before you

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pick a given treatment,

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because we'd like to
repeat these treatments,

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not necessarily do them in a series,
but keep stimulating the skin over time.

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Circle back in six months, a
year or two years, three years,

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and push the skin again.

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It's easier to do treatments that
don't have a high disposable cost.

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It's easier to do treatments that
have no recovery and that are

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non-invasive, but sometimes
depending on stage of aging,

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it's better to pick something that has
some of those downsides associated with

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it, but is going to give you
a more meaningful result.

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Using these technologies can
greatly delay the need for the full

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surgical facelift and neck lift,
and that's a paradigm shift.

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If you treat early and often, you
won't need to use the big option,

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the facelift and neck
lift until much later.

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Thank you Dr. Bass for
sharing your expertise and
bringing this series to such a

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00:17:26,720 --> 00:17:27,920
well thought out close.

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

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Follow us on Apple Podcasts,

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00:17:35,030 --> 00:17:37,130
write a review and share
the show with your friends.

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00:17:37,520 --> 00:17:40,640
Be sure to join us next time to avoid
missing all the great content that's

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00:17:40,640 --> 00:17:44,150
coming your way. If you want to
contact us with comments or questions,

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00:17:44,180 --> 00:17:45,050
we'd love to hear from you,

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00:17:45,560 --> 00:17:49,790
send us an email at podcast@drbass.net
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