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Habits, Cultural Norms, and Rapid Advances In Technology Have Dramatically Changed the Aesthetic Medicine Landscape

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Amy B. Lewis, MD, explores the evolution of aesthetic dermatology, delving into injection sophistication, devices, and top procedures.

In the past decade or so, aesthetic medicine providers have become more skilled, creative, and holistic in their treatments. With any remaining stigma of cosmetic improvements long gone thanks to factors such as the "Zoom" effect, celebrities, and influencers; patients are seeking skin rejuvenation services at a younger age. Women, along with an increasingly growing number of men, desire natural but more youthful looking results. Patients want safe and comfortable options that allow them to still "look like themselves" as they often say, prioritizing noninvasive or minimally invasive alternatives to surgery, opting also for little to no downtime.

Patients are also eager to expand their skin care regime outside of the office setting by first adding medical grade products to be used at home. They are also excited to learn about and incorporate at- home devices/treatments. This trend is rising in demand, especially with gadgets for hair removal, red light therapy masks, and “anti-aging”/skin tightening devices. Patients are looking for customizable treatments but also quick and easy “do it yourself” methods. At the same time, aesthetic providers seek to add offerings and technology that helps them both streamline and grow their practices.

The concept of personalized treatments tailored to a patients' unique need is paramount to what we do. The recent advances in our field have allowed us to offer even more customized solutions. Patients are also starting their rejuvenation journey sooner as a preventative measure, ensuring their ability to maintain a youthful appearance. We call this trend “pre-rejuvenation”, to stave off the aging process, instead of looking to reverse damage already done. We frequently outline a comprehensive treatment plan that allows patients to be proactive and achieve personalized results.

Regenerative medicine with platelet-rich plasma injections, stem cell and exosomes are an exciting area that promises to explode as research and innovation speeds forward. Many of these therapies are geared toward stimulating collagen, elastin, and hyaluronic acid production along with a decrease in the inflammation in the body.

Injection Sophistication

When fewer products were available and providers less experienced, there was more of a tendency to “line chase”. The first filler was approved for nasolabial folds, and early procedures would often leave patients looking bulky and un-natural. Providers would inject neuromodulators in a very textbook manner, failing to account for facial muscle activity, asymmetry, or individualization.

Today we are much more sophisticated and have a deeper understanding of the anatomy and how each injection might integrate or affect the facial structure or musculature. We can tailor our choice of product(s) and injection technique to that patient's facial characteristics. As we attempt to best shape or sculpt the face, we often “think outside the box” using off label techniques with FDA approved products.

We are lucky to have a much larger and more advanced arsenal of neuromodulators, and fillers to choose from. We have an in-depth understanding of the rheology/characteristics of the fillers or the specific differences and similarities between the multitude of “toxins” available today. Fillers vary in characteristics such as resistibility and elasticity which makes them more suitable for specific areas. A more elastic and easily spreadable filler is used around the mouth, for example. We can therefore tweak our treatments to get better, more natural looking results. It’s like using multiple paint brushes to complete a beautiful canvas.

Energy-Based Aesthetic Treatments 101

What is:

  • Dynamic muscle stimulation? Dynamic Muscle Stimulation (DMA) or Facial Muscle Stimulation, activates facial muscles through electrical stimulation, replicating a natural workout process at a heightened frequency and intensity. This technology effectively tones and lifts all facial muscles achieving a well-defined, toned and lifted look, facelift-like effect.
  • Radiofrequency? Radio waves give off heat that prompts the skin to produce more collagen and elastin. The treatment also speeds up cell turnover, so the skin gets firmer and thicker over time.
  • Ultrasound technology? Bypassing the skin's surface, ultrasound energy is delivered to targeted structural tissue which stimulates collagen growth, acting to smooth wrinkles, improve elasticity, reduce the appearance of jowls, lift, and tighten skin.
  • Intense pulsed light? IPL is a non-laser light-based energy treatment primarily used to improve pigment and vascular skin imperfections, which improves the texture and color of the skin.
  • CO2 laser? Fractional CO2 resurfacing or ablative fractional resurfacing uses simultaneous vaporization and heat delivery of the CO2 laser wavelength to cause a renewal of the skin surface. It also aids in skin tightening and new collagen development in the subsurface of the skin resulting in improvements in g both skin tone and texture.

Devices

The demand for energy-based aesthetic devices is booming as technology such as dynamic muscle stimulation (DMST), has entered the market and microneedling radiofrequency has improved dramatically. These approaches can target the root causes of aging, the muscles, as well as tighten the skin and can help stave off the need for more invasive procedures. Additionally, devices allow us to create customizable treatment plans that effectively target patients' most vital aesthetic needs. Over the last several years, there have been several studies that demonstrate comprehensive treatment protocols must target the facial muscles, as well as the dermal layers, to properly address signs of aging.1 Fillers and injectables only combat a portion of the problem, whereas some devices can treat both skin and the underlying structural issues that accompany natural aging.

In the past, we concentrated on the face—now we look towards whole body rejuvenation. Today we are treating the neck and decolletage, arms, hands, and body contours too. Advances in devices that use a variety of energy sources let us noninvasively address the skin and the muscle layer with applications all over the body.

In prior years, many patients would immediately jump to surgery to address cosmetic concerns. Now we have noninvasive options that can give an overall lifted and refreshed look with little or no downtime. This can postpone or eliminate the need for a more invasive surgical procedure in the future. These devices also enable additional support options for those patients who still seek injectable or other treatments. These devices allow us to maintain or elongate the aesthetic improvements from other treatments performed in the office.

The days of facelifts being the only option in terms of aesthetic treatments are long gone, ushering in a new generation of non-or minimally invasive, as effective, treatment options that are approachable and safe for everyone.

Top Procedures

In my practice, patients continue to seek toxin injections to stop or reverse the worry lines and deep creases from chronic muscle contraction/stress It can prevent lines before they become too deep, with prejuvenation like micro-Botox (onabotulinumtoxin A; Allergan Aesthetics) or Dysport (abobotulinumtoxin A; Galderma) for rosacea or pore tightening. There are many techniques, and it has broad application with our use of these products becoming more sophisticated.

Fillers and volumizers are not going anywhere, but the way in which we use those also continues to evolve. Combination therapy with different fillers like Bellafill (non-resorbable polymethylmethacrylate microspheres; Suneva Medical) or Juvederm / Restylane / Versa (crosslinked hyaluronic acid; Allergan Aesthetics/ Galderma / Prolenium ) or CAHA ( radiesse /Merz) with a toxin like Daxxify (daxibotulinumtoxinA-lanm; Revance Therapeutics) or others is extremely popular. Reversable fillers and longer lasting products are also on the horizon. These will continue to improve in their bioregenerative and biostimulatory effects.

When it comes to devices, triLift, by Lumenis is one of the more popular and requested treatment options. triLift’s Facial Muscle stimulation technology is groundbreaking in how it allows us to create targeted treatments for every face with immediate and profound results. triLift is a noninvasive three-part treatment. First is the Dynamic Facial Muscle Stimulation (DMStTM), an entirely new treatment category and a revolutionary breakthrough that has disrupted the aesthetics market. DMSt stimulates muscle contractions mimicking physiological muscle function, but at a significantly higher frequency and intensity. Combining dynamic application mechanisms, its unique engineering allows safe supramaximal contractions, avoiding muscle overexertion, allowing higher energy application—X100 stronger than Static EMS/TENS1, ensuring unparalleled efficacy and safety. The device also allows full adaptation to patients' needs and individual facial anatomy. This personalized approach is tailored to the patient's facial condition and the desired facial results. triLift (DMSt) results in significant and natural-looking results from the first treatment.2 Second is the TriPollar RF radiofrequency treatment, which works to thicken and strengthen the skin’s deeper level (dermis) by generating collagen and elastin. Finally, triFX Radiofrequency Microneedling stimulates the wound-healing process to regenerate skin cells in the superficial epidermis, improving fine lines, texture, crepiness, and age spots.

Devices, such as triLift, solve an opening in the aesthetic market – those individuals who seek to reduce the need for fillers, a more natural solution or aesthetic treatment options that are approachable, safe, non-surgical, and allow the patient to return to daily life immediately upon leaving the clinic. I believe that going beyond the skin, and finally being able to effectively target the underlying muscles will enhance offerings across any clinic and provide patients with even better results.

Microneedling RF is also important in my practice because it has so many benefits. It helps tighten, reduce pore size, fine lines, and wrinkling, but it also can be combined with other modalities to make it even better. Microneedling RF combined with IPL, (SmoothGlo; Lumenis) for example, achieves more pigmentation improvement than with IPL alone. I also use add-ons with microneedling RF. For example, once those channels are open, I might put PRP or Sculptra (injectable poly-L-lactic acid; Galderma) with a micro toxin on top. We can fine-tune these applications and get more out of them than in the past.

With advances in devices such as triLift, and injectables such as Bellafill, bio stimulators, along with the multiple variations of Restylane now on the market, the way in which we approach the patients’ needs is changing for the better. More comprehensive treatment options, approachable and safe technologies, and little to no downtime treatments that finally address the root causes of aging are leading the change and building the new landscape of aesthetic medicines.

[1] compared to home use EMS / TENS devices

[2] treatment protocol is combined of 5 treatments, 1 week apart for maximal long lasting results

Amy B. Lewis, MD, is the owner of Lewis Dermatology & Associates in New York City and a Clinical Associate Professor at Yale University School of Medicine, New Haven, Connecticut. Lewis is a nationally renowned medical expert and consultant in the field of cosmetic dermatology, and she has served on a myriad of medical advisory boards and has been featured in the media as an expert on sun damage, sun protection and safe tanning, laser treatments, Botox, and other cosmetic procedures. She has been a certified speaker and trainer for Allergan, Galderma, Merz, Suneva, Lumenis, Candela, Sofwave and more.

Lewis has a special interest in cosmeceuticals and has been a consultant or advisor for many skincare companies including Kiehls, Canderm Pharma, IS Clinical Skin Care, Helena Rubenstein, Orlane, Medicis, Neutrogena, Guthy-Renker, L’Oreal / La Roche Posay, Unilever, Garnier , Galderma, Rion Plated ,Nutritioniste, Alastin, Neocutis, and more. She lectures frequently at academic meetings and has numerous publications in her specialty, including several chapters in both plastic surgery and dermatology books.

Amy B Lewis MD

120 East 75th st
NYC, 10021
212-288-6133 (office)

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