While there is no real variance in how procedures are performed on women versus men, differences exist in the anti-aging goals, and the ways in which practitioners address areas that satisfy both gender and individual patient needs.

Both genders tend to pursue comparable aesthetic results; however they may be focused on different body areas, said Terrence Keaney, M.D., F.A.A.D., a dermatologist in Arlington, Va. “The use of injectables to restore youthful facial features is important to both men and women. Women care more about specific facial areas, such as the cheeks and lips, while for men it’s more about the eyes and jawline. Also, men often seek body contouring, especially in the submentum and abdomen, as well as non-surgical hair restoration with platelet-rich plasma (PRP). Hair loss is important to women, as well, but it is not a top cosmetic concern as it is for men,” he said.

“Definitely more men are seeking aesthetic solutions,” expressed Gregory P. Mueller, M.D., F.A.C.S., a plastic surgeon in Beverly Hills, Calif., who noted that over 40% of his patients are male. “They are coming in for facial procedures like neurotoxin injections, which have been popular with men for the last ten years.”

Nevertheless, he continued, “When men come in they’re not asking for higher cheekbones or a change in the way their face looks. Generally, they want to retain their facial shape, but maybe improve skin quality, tone and texture. Men want to make their skin look younger, they don’t want to look ‘done.’”

For Shino Bay Aguilera, D.O., a cosmetic dermatologist and dermatologic surgeon in Fort Lauderdale, Fla., there are important distinctions between men and women in aesthetics. “Females tend to be more body conscious, worrying about cellulite, wrinkles and laxity, their arms and excess fat. Because of the way they dress, a lot more flesh is exposed. Men can hide pretty much any of these issues from others.”

“In my experience, lots of men worry about crow’s feet more than anything else,” Dr. Aguilera commented. “Their second area of concern is the double chin. Off the face and neck, the waist and love handles are of great concern to men.”

In the body treatment category, men now realize that they can have cosmetic medical procedures without having to deal with the invasive nature of surgery. “There has been an uptick in body treatments for men, as well as skin tightening procedures,” Dr. Mueller reported.

According to experts, both men and women are drawn to non-invasive solutions, such as cryolipolysis, ultrasound, laser or radiofrequency (RF). truSculpt® 3D from Cutera, Inc. (Brisbane, Calif.), is one such modality, based on monopolar RF. This system takes a multidimensional approach to decrease circumference and diminish fat by delivering clinically therapeutic temperatures to the subcutaneous adipose tissue to achieve high clinical efficacy quickly, with enhanced safety and comfort.

Notably, many men are copying women in seeking certain aesthetic procedures. “After seeing their wives or significant others transform into a younger version of themselves, men generally start to feel concerned about their weight, the inability to eliminate stubborn body fat, wrinkles and aging skin,” said Shelena C. Lalji, M.D., an OB/GYN and medical director of Dr. Shel Wellness & Medical Spa (Houston, Texas).

“Neurotoxin injections and/or non-invasive fat reduction treatments are the gateway procedures for men in my practice,” she shared. “Both types of procedures are very quick and painless, and patients are able to see the results fairly quickly.”

While most referrals of husbands and boyfriends are made by significant others, there is actually a combination of referrals at work, Dr. Keaney noted. “Male-to-male peer referral is the most effective, but the most challenging to build. Men are often reluctant to reveal that they had a cosmetic procedure to their male friends or colleagues.”

Compared with women, “Men are a little more clandestine than women,” noted Dr. Aguilera. “While they are willing to do anything they can to make themselves look better, they also want no downtime or indications that they got cosmetic work done. They are most comfortable with not letting anybody find out that they did it. However, I see the wives come in and get a body shaping treatment and next thing you know the husband or boyfriend is in our office, asking about it.”

The growth of male aesthetics has also been affected by the up-and-coming Millennial generation, which is perhaps more dedicated to aesthetics than any other demographic.

“The Millennial patient is a lot more cosmetically adventurous and educated about procedures,” Dr. Aguilera pointed out. “We see many young patients come in for enhancement. The older patients need this kind of therapy, but the younger ones want it.”

“Millennials see a friend of theirs on social media who has had some work done, for instance,” said Dr. Mueller. “They are growing more aware of what is available, and they are going for it.”

Similarly, gay men are more adventurous, almost the way a woman would be, according to Dr. Mueller. “There’s a whole world of gay men talking to other gay men about what kinds of aesthetic procedures they have had. Gay men will talk about it more than straight men. They are not afraid to come in and ask, what do you think I need? I’m not happy about the way my body looks. Should I have liposuction? They are a bit more open to what we suggest and they are very dedicated. They will refer their friends to me if they are happy with the results. It’s quite an incredible patient-to-patient referral.”

In recent years, rejuvenation of the genital area has become considerably more popular with both men and women. Penile enhancement is a growing niche in the aesthetic industry; however, most of the advances in techniques and technologies, including clinical studies and FDA approvals, have been made in non-surgical vaginal rejuvenation procedures.

Experts pointed out that currently most of the penile enhancement procedures being used are experimental, however, procedures that extend the penis’ length and girth, should become mainstream soon.

“Regarding girth enhancement, everything out there is considered, at best, experimental,” confirmed Paul Perito, M.D., a urologist in Coral Gables, Fla., who performs over 500 penile implant surgeries per year.

“When it comes to the glans, work has been done in Korea in the use of filler-type materials, such as PMMA or different forms of hyaluronic acid (HA). One evidence-based approach I’ve heard of is the use of a synthetic nanoparticle that shows promising results in increasing girth.”

Eventually, this developing penile cosmetic niche will be brought into mainstream medicine, Dr. Mueller insisted. “It is going to be a huge area. It doesn’t matter if a guy is gay or straight. Yes, there are some unresolved issues, but think women and breast implants. Breast implants remain very popular even though there are lots of problems with them,” he stated. “With penile enhancement, there are numerous surgical procedures out there that are not good and produce major deformities. I’ve seen some results using silicone that have been disasters. If somebody can come up with an answer to that then yes, the interest will be very high.”

By comparison, “Females are asking for procedures that are far less experimental, such as vaginal rejuvenation – from surgical to energy-based techniques,” Dr. Perito said.

For instance, the top trends in feminine rejuvenation include any non-invasive treatment option that improves both the function and appearance of the vagina.

“Women are highly interested in any treatment that allows them to remain as comfortable as possible, with little to no pain, downtime, prescription medications and/or invasive surgeries,” Dr. Lalji acknowledged.

Women’s pelvic muscles go through a great amount of trauma throughout pregnancy, childbirth and even aging, causing the pelvic floor muscles to weaken and not function properly, Dr. Lalji continued. “When this happens, women experience laxity and incontinence, as well as a large change in the appearance. This typically leads to sexual dysfunction and/or a decline in sexual desire. Oftentimes, this results in a loss of self-confidence, feelings of embarrassment and a tailoring of their lives according to this,” she said.

In Dr. Lalji’s experience, when it comes to successful approaches to managing patient expectations in non-invasive feminine rejuvenation procedures, “The results vary from patient to patient, but one aspect that remains constant is that nearly all my female patients have experienced life-changing results,” she indicated. “In order to successfully maintain the results and expectations for this type of treatment, it is important that women go through a series of maintenance sessions on an ongoing annual basis.”

Easy-to-use energy-based technologies (RF, laser, ultrasound) have put vaginal rejuvenation on the radar for a lot of practitioners.

“We offer an RF-based procedure and while it has been a slow uptake it is an incredible technological approach,” Dr. Mueller stated. “The treatments not only help with sexual function, but also with bladder control, as well as other conditions that are now fairly easy to treat compared with surgery.”

Characteristic of this type of device, ThermiVa® from Thermi, an Almirall company (Dallas, Texas) is a temperature- controlled system that uses RF-based energy to gently heat tissue so that women can reclaim their intimate wellness without discomfort or downtime. The ThermiVa electrode is designed to treat the internal and external anatomical features of the vagina.

Similarly, Votiva from InMode (Richmond Hill, Ontario, Canada) uses FormaV or FractoraV RF technologies to address the internal and external areas of concern. FormaV’s subdermal heating technology applies uniform RF heat to internal vaginal tissue and external vulvar laxity or labial hypertrophy. Treatment addresses a variety of intimate wellness concerns such as aging, hormonal changes and/or physical damage. FractoraV utilizes customized fractional RF energy to improve superficial skin tone problems and for skin tightening. Full-depth heating improves elastin and collagen remodeling to positively impact a woman’s feminine health and quality of life.

Among CO2-based devices, V-Lase from Lasering (San Ramon, Calif.) is a non-ablative, non-fractional CO2 modality for feminine rejuvenation. V-Lase creates mild thermal damage in the mucosal lining and underlying tissues of the vaginal canal and vulva. This remodels existing collagen and induces fibroblasts to create new collagen, elastin, reticular fibers and glycosaminoglycans. Treatment is safe, pain-free, non-invasive and results in thickening, tightening and more elastic and pliable vaginal walls, as well as a restoration of vaginal moisture and pH balance.

At the practice level, the problem is not a lack of technology, but rather how do you bring up vaginal rejuvenation during the consultation? “For us, performing these types of treatments and getting the great results is easy,” Dr. Mueller expressed. “The biggest challenge is in the conversation. You don’t want to make the person feel uncomfortable during the consult.”

In reality, anyone seeking aesthetic treatments, regardless of the desired procedure, gender or generation, wants to build a solid trust with the physician performing the work. “The leap into cosmetic procedures can be a reluctant one,” said Dr. Keaney. “Trust in the physician is critical for a patient to make that leap. Do not overpromise results and carefully explain the side effects. With men, we see lower tolerance of side effects, such as bruising, because of their work schedule
and concern of being identified as having had a procedure, etc.”

As described by Dr. Perito, male aesthetic patients are ‘one and done.’ “When you set the expectations, they are on board,” he said. “They want to come in and get it done that day. They don’t want to wait. If you string them along then they lose interest. Give them a plan and they will stick with it.”

The epidemic of opioid-related deaths sweeping the country has lawmakers and regulators in Washington, D.C., and state capitals scrambling for answers. And while doctors generally welcome the attention to the crisis, many also fear that the solutions being proposed and enacted will do more harm than good.

The concern among physicians and public health and pain management experts is that laws and regulations designed to limit use of prescription narcotics, however well-intentioned, are yet another constraint on doctors’ ability to treat patients as they think best.

Worse, they say, some of the limitations on prescribing could result in patients turning to heroin or buying the medications on the street. And because heroin in particular now is often laced with fentanyl and other synthetic painkillers, doing so astronomically increases the risk of death.

Balancing needs of patients versus the community

Still, nearly everyone agrees that the staggering death toll from opioids—now around 115 people each day, according to the CDC—needs to be reduced.

That responsibility often falls to primary care doctors, who write about half of the nation’s opioid prescriptions, according to the CDC. It also leaves them to grapple with the question voiced by Alan Schwartzstein, MD, a primary care physician in Oregon, Wisc.: “How do we provide patients with adequate management of their chronic pain without having medications that could be a danger to themselves or others out in the community?”

While opioid-related deaths have been rising for well over a decade, government efforts to address the crisis only got underway in earnest in 2016. That’s when the CDC issued its comprehensive “Guideline for Prescribing Opioids for Comprehensive Pain,” and President Obama signed into law the “Comprehensive Addiction and Recovery Act of 2016.”

Around the same time, state legislatures began considering—and in some cases adopting—laws aimed at curbing opioid abuse. As of July 2017, 23 states had passed legislation with some type of guidance, limit, or requirement related to opioid prescribing, according to the National Council of State Legislatures.

Most of the state laws limit first-time opioid prescriptions to a set number of days, ranging from three to 14. Many also mandate that doctors consult their state’s Physician Drug Monitoring Program (PDMP) before writing an opioid prescription, to ensure that the patient isn’t getting medications from multiple prescribers.
 

Opposition to new CMS Rule

The most recent action aimed at reducing opioid use occurred in April of this year, when CMS approved a rule denying coverage (with some exceptions) for Medicare Part D beneficiaries whose total daily opioid dose exceeds 90 morphine milligram equivalents (MMEs). The rule also limits coverage for patients receiving opioids for the first time to a seven-day supply, with no exceptions.

The rule generated significant opposition from physicians and pain experts, dozens of whom signed a letter stating, among other objections, that the policy isn’t consistent with the CDC guideline, and it doesn’t include any metrics for evaluating the rule’s impact on patient health or access to care.

Among the letter’s signatories was Thomas Tape, MD, MACP, professor of internal medicine at the University of Nebraska Medical Center, and a member of the core group of experts that advised the CDC in developing its opioid guidelines. “I’m a firm believer of guidelines in terms of information to physicians regarding the hazards of high-dose opioid prescribing,” Tape explains. “But at the same time, physicians need to be allowed to exercise their clinical judgement about the appropriate course of therapy for a particular patient without interference from governmental entities, because there are so many exceptions to any general rule.”

Tape, who maintains a clinical practice, distinguishes between what he calls “legacy patients”—those who have been on high doses of opioids for months or years—and patients who’ve been prescribed opioids more recently and are still on relatively low doses. One of the goals of the CDC guideline and subsequent laws and regulations, he says, is to ensure that patients in the latter group don’t become part of the high-dose group.

“But we also have to recognize there are no easy answers for dealing with that high-dose legacy group,” he adds. “You can’t just make the problem go away by saying we won’t pay for that kind of [high-dose] prescribing anymore, because that throws patients into a state of withdrawal.”

Like Tape, Schwartzstein believes that getting patients off opioids, or just lowering their dosages, is a difficult process that has to be tailored to each patient’s needs. “My primary goal is to manage chronic pain so that people can be as functional as possible, so I don’t take opioid pills away from people just for the sake of taking them away. It’s all based on an individual assessment between myself and the patient,” he says.

Wisconsin, where Schwartzstein practices, has no limitations on the quantity of opioids a physician can prescribe, but it does require prescribers to take two hours of continuing medical education on the topic, and to consult the state’s PDMP if they write a prescription for more than three days’ worth of the medications.

Even so, Schwartzstein says, he has changed his approach to opioids over the last few years as their danger has become more apparent. For patients experiencing acute pain, he now generally prescribes a three- to seven-day supply, whereas before he would prescribe for up to 14 days. 

For patients with chronic pain, Schwartzstein first tries to address it with non-pharmaceutical solutions—exercise and physical therapy—and/or non-opioid medications. “If I do start prescribing opioids, it’s only after a careful discussion about the benefits and risks, either for the patient or others who might potentially access them,” he says. He also requires patients to sign a contract under which they agree to get prescriptions only from him, to get the prescriptions filled at a designated pharmacy, and undergo periodic urine screenings.

 

Growing ‘opioid phobia’

For Dan Glatt, MD, an internist in Burlingame, Calif., specializing in pain and addiction medicine, obstacles to prescribing opioids have come not from any new laws or regulations, but from payers.

He cites the case of two patients who’ve been stable on their medications for several years, but whose insurance (which they get through their spouses who both work for the same employer) recently began limiting its opioid coverage to 90 MME per day, far less than the patients had been using. Now, Glatt says, the patients are having to pay out-of-pocket for their pain medications.

“It puts unnecessary stress on the patients and thereby on their spouses who are the actual employees and who are afraid to complain about the situation because they don’t want to lose their jobs,” he says.

In addition, Glatt notes that a growing number of physicians in his region now refer patients to him out of what he calls “opioid phobia.”
“Docs who were prescribing now are afraid to because they don’t want to show up on a list or think the DEA is going to show up at their door,” he says. “They either want a blessing from me because they know I treat addiction and pain, or they just don’t want to take care of these patients anymore, even though the patient’s doing fine and has been stable on their meds for years.”

Like many specialists in addiction medicine, Glatt believes the solution to the opioid crisis lies in devoting more resources to helping addicts and keeping outside interference to a minimum. “It gets more and more frustrating to practice clinical [addiction] medicine when nonclinicians are telling us how to prescribe,” he says. As for what would help, he cites the need for more detox services and for medically assisted treatments, such as opiate blockade and replacement therapies. 

 
Burdens on practice

Georgia, where internist Sandra Fryhofer, MD, MACP practices, recently enacted several laws aimed at curbing opioid abuse.

Beginning July 1, physicians who are licensed to prescribe the medications must register with the state’s PDMP, check the database when they first prescribe a controlled substance for a patient and every 90 days thereafter (and document that they’ve done so), inform patients about the addictive properties of opioids before prescribing them, and take at least three hours of CME on safe opioid prescribing before receiving or renewing their medical license.

The law allows practices to assign up to two staff members to check the PDMP, thereby relieving physicians of some of the time required. Even so, “It’s going to be a burden because everyone is already busy in a small primary care office,” she says, adding that the process would be easier if the PDMP could be integrated into electronic health records.  On the other hand, “It’s not too much to ask if we can save a life,” she adds.

The Medical Association of Georgia also lobbied unsuccessfully for a law that would have required commercial insurers in the state to provide coverage for opioid addiction treatments and opioid alternative treatments for patients. “All these things are ways that we could keep from having to give patients pain pills,” she says.

Fryhofer adds that the law’s failure is emblematic of a larger problem: Too few lawmakers, regulators and payers involved in trying to solve the opioid crisis truly understand its complexities or the resources the effort requires. “But they do understand we have a deadly epidemic on our hands that continues to claim more and more lives and something has to be done to stop it,” she says. “And they know that a lot of the cycle of opioid prescribing begins with clinicians, so they want to make us part of the solution.”

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Tips for opioid prescribing

With all the legislative and regulatory efforts to reduce opioid use, can primary care doctors still prescribe the medications without running afoul of the law? The answer is “yes,” but experts caution that it takes work.

“If you choose to prescribe opioids for patients, the most important thing is to have properly documented records,” says Dan Glatt, MD, an internist and partner in a pain and addiction practice in Burlingame, Calif. Documentation should include the patient’s medical history and physical exam, the rationale for prescribing opioids, and discussion of the risks and benefits. In addition, doctors need to consult their state’s Physician Drug Monitoring Program—and document they have done so—to ensure against duplicate prescribing, and administer random urine tests. “Doing these things is the only way to be safe with prescribing,” he says.

Anna Lembke, MD, medical director for addiction medicine at the Stanford University School of Medicine, also stresses the importance of documentation, along with determining if the patient has a history of addiction or substance abuse. “The ‘don’t ask, don’t tell’ approach [towards opioids] that many doctors had been using for decades is no longer acceptable,” she says. “Now we know what the risks are and there’s no longer any excuse not to ask about it and monitor for it.”
 

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The case for outside intervention

Anna Lembke, MD, knows that where government regulation of opioid prescribing is concerned, she is an outlier. While most doctors resist any limits on their ability to treat patients as they think best, Lembke thinks that reducing opioid use requires intervention by legislators and other outsiders.

Lembke’s willingness to accept government-imposed limits on opioid prescribing is based on the need to counter what she calls “perverse incentives” in the nation’s healthcare system to overprescribe the medications, as demonstrated by the fact that as of 2015  American physicians were prescribinig three times more opioids than in 1999, and nearly four times more than their European counterparts, , according to a 2017 JAMA article.

Among these incentives, she says, is the influence that pharmaceutical manufacturers have wielded, and continue to wield, over organizations and agencies meant to protect patients and advocate on their behalf. She points to a March 2018 draft report to the director of the National Institutes of Health recommending, among other actions, that the institute no longer accept funding for public/private partnerships from pharmaceutical companies involved in opioid-related litigation. 

The growing number of physicians leaving private practice to work for hospital systems creates another reason for doctors to overprescribe opioids, she says. “Employed doctors are under enormous pressure to see patients quickly and to get good patient satisfaction scores because those can impact professional advancement,” she says. “Opioids work really well to address those needs, at least in the short-term, so prescribing them is the easy thing to do.”

Still another factor favoring opioid prescribing, Lembke says, is Americans’ attitude towards pain. “In general, I think the cultural trend is toward the belief that any amount of pain is too much,” she says. And while that attitude stems from a variety of causes, the pharmaceutical industry promotes it. “Their attitude is, ‘If you’re experiencing any pain, you have an illness and your doctor has a responsibility to treat that,’” she says.

Given all the incentives in favor of opioid prescribing, Lembke says, “I think there needs to be external controls, because left to their own devices doctors won’t be able to limit their prescribing to the extent necessary to impact this public health crisis.”

Sponsored

Providers and patients alike continue to reap the benefits of utilizing radiofrequency (RF)-based energy for non-surgical, no-downtime body shaping and skin rejuvenation procedures. As a versatile example of this trend, the Thermi250® device from Thermi, an Almirall Company (Dallas, Texas) employs temperature-controlled RF that delivers a tailored treatment for non-invasive, non-ablative body rejuvenation for people of all skin types.

With both monopolar and bipolar capabilities, the Thermi250 platform can be used to improve fine lines, wrinkles and crêpey skin laxity of the eyelids; upper and lower lips; and front of the neck; as well as address the appearance of cellulite. The ThermiSmooth procedure can also serve as an adjunctive therapy performed prior to or after another treatment, to address lax skin and other skin-related concerns.

“Some fat reduction treatments using other devices can be painful, so I prefer using the Thermi250 for the ThermiSmooth body procedures,” expressed Paul S. Nassif, M.D., a facial plastic and reconstructive surgeon in Beverly Hills, Calif. “I’ll use it after a fat reduction procedure, but overall I like using it before, just to stimulate the collagen. It offers a comfortable procedure where you don’t have to use anesthesia.”

As reported by Dr. Nassif, heating tissues directly via RF after a fat loss treatment causes a contraction resulting in tighter skin. 

“Studies have shown immediate heating facilitates collagen denaturation with resulting fibril contraction and tissue thickening,” Dr. Nassif explained. “An inflammatory wound healing response ensues with long-term neocollagenesis and further tissue contraction. Selective heating and tightening of fibrous septae within the subcutaneous layer likely accounts for immediate contour changes in the skin after treatment.”

ThermiSmooth post-procedure treatments can be combined with other fat reduction modalities, such as cryolipolysis. “Any time you actually do a fat reduction treatment there is a fear you’ll have a little loose skin,” Dr. Nassif shared. “Wait a few weeks before you do ThermiSmooth. It does seem to result in a better outcome.”

In preparing patients for fat reduction, followed by a ThermiSmooth procedure, Dr. Nassif recommends beginning the regimen with tight, taught skin. “I suggest a preparatory application of ThermiSmooth to create a tight tissue foundation. Following the fat loss procedure, do a final ThermiSmooth skin tightening treatment to ensure that the result will be smooth, tight and with reduced fat,” he said.

ThermiSmooth also works on different body areas, according to Jason D. Bloom, M.D., a facial plastic and reconstructive surgeon in Ardmore, Pa. “For instance, a ThermiSmooth procedure around the eyes. The device is about the size of a marking pen and literally lets you get in close to the eye.”

You can really see a change in the wrinkles especially in the periorbital region, Dr. Bloom added. “It tightens up that area. In some patients I’ll do the whole face and the neck, too. Usually, I will sell them a series of three treatments, around six to eight months apart. If you consider collagen generation, it is about six weeks before you see collagen production. I do two to three treatments and then after two months I’ll take pictures and see a difference.”

Dr. Bloom utilizes the ThermiTight for fat reduction, which is powered by the ThermiRF platform. “I’ll use ThermiTight on the jowls and neck, which is going to give you the best skin tightening in those areas. Years later, I ask them to come back in for a series of ThermiSmooth sessions, which allows them to maintain their results.”

The nice thing is patients like the feel of it, added Dr. Bloom. “The ThermiSmooth procedure feels like a hot stone  massage. Also, it is safe so the treatments can be delegated, meaning it is not something that the physician necessarily has to do.”

Patient selection is always up to the physician’s discretion, noted Dr. Nassif. “We recommend treating areas with good skin quality or turgor, and texture, without excessive weight fluctuation or excessive photodamage, and in patient populations capable of collagen regeneration.”

As reported by Dr. Bloom, “The idea of percutaneous RF has been hugely popular in my practice among the patients that I call the ‘tweeners.’ This would be the mid-40s to early-50s patient that is not ready for a surgical face- or neck-lift procedure. RF and even topical or transcutaneous RF, where you’re actually massaging the skin, has always been the gold standard for tightening without surgery.”

ThermiSmooth is a go-to therapy for Millennials, as well, Dr. Bloom continued, “Because they don’t have as much skin laxity as someone who is older. I will treat Millennial necks with ThermiTight. It is perfect for them. First I’ll do a little microliposuction and then tighten the skin.”

Patient satisfaction is very high, stated Dr. Nassif. “Our customers are happy. Remember what is important about this is expectations. We have to make sure the patient knows that this is not a face-lift, and that this procedure will achieve a nice tightening with minimal discomfort. However, you do have to wait for that collagen contraction to see the full effects.”

In Dr. Bloom’s experience, the lack of downtime is another big selling point with ThermiSmooth. “People can go back to work immediately,” he said. “Many of them say it is relaxing, that it feels warm and they like it. And it actually produces real results. You can see tightening after as few as one or two treatments.”

Return on investment (ROI) is high because there are no disposable costs, Dr. Bloom pointed out. “The Thermi250 system is one of the best pieces of equipment I’ve ever bought. There’s a low overhead and no disposable. With a lot of devices, you pay for the tip or some disposable, but with Thermi250 you clean the handpiece and you’re ready to go to the next patient. In addition, patients also save on the cost of procedures.”

The Discovery PICO Plus laser by Quanta System (Milan, Italy) combines powerful Nd:YAG and Ruby wavelengths to treat tattoos, scars and more. With pulses ranging from microseconds to picoseconds, plus multiple handpieces and spot shapes, this innovative device also delivers flexibility.

Having the Discovery PICO laser’s maximum 1.8 Gw (at 1064 nm) allows for spot sizes up to 7.5 mm, with the right fluence for treating deep pigment, such as a tattoo on a man’s back, quickly. “I’m surprised by the amount of energy you can deliver with a very large spot size,” said Matteo Tretti Clementoni, M.D., a plastic surgeon in Milan, Italy. “The bigger the spot size, the deeper the penetration.”

With the 532 nm, 1064 nm and Q-switched 694 nm wavelengths, Dr. Tretti Clementoni can treat most classic tattoo colors (black, red, green and purple). During successive treatments spaced two months apart, he reduces the spot size because it takes higher energy to pulverize ever-smaller ink particles with picosecond pulses. Compared to Q-switched lasers, with the PICO Plus, “We can reduce the total number of sessions by at least 20%, and I don’t have ‘tattoo ghosting’ as in some cases with Q-switched modalities,” he reported.

Dr. Tretti Clementoni considers the device’s square-spot handpiece critical for early tattoo removal treatments. “With the square spot you can place one spot exactly next to the other, without a very high frequency, resulting in precise procedures,” he explained.

Conversely, the round-spot handpiece is useful for treating rounded lesions such as solar lentigines. “You cannot put a round spot exactly next to the other,” Dr. Tretti Clementoni pointed out. “So, to cover an area you have to overlap, or leave some untreated areas to allow feathering of the final result.”

With the PICO Plus fractional handpiece, “I love what we can do for scars. Now we are sure to achieve collagen remodeling
due to the laser-induced optical breakdown (LIOB) we are creating in the superficial dermis,” Dr. Tretti Clementoni expressed. “This technology focuses enormous amounts of energy on very small spot sizes to break up tissue. “The LIOB produced via the 1064 nm wavelength is like an explosion in the superficial dermis.”

Damaging the dermis drives collagen remodeling and collagen production, Dr. Tretti Clementoni continued. “That is why we see such good results on atrophic acne scars, as well as on most traumatic and surgical scars.”

To treat acne scars, Dr. Tretti Clementoni delivers medium doses (with topical anesthetic and a Zimmer cooler), using a lower range for darker skin. “I’m doing five to seven passes on the area, with a frequency of 10 Hz. Instead of a stamping technique, I’m using a very high frequency so I’m able to use a painting technique on the skin,” he noted.

Post-procedural pinpoint bleeding gives way to inflammation and erythema, which reportedly disappear after two to five days.

“Patients can see results after the second session, but with my protocol, I’m doing four sessions spaced three to four weeks apart,” Dr. Tretti Clementoni advised. “Because we have collagen production, I see maximal improvement six months after the last procedure. In a nutshell, I love the Discovery PICO Plus. It is one of three devices in my office that I run for 12 hours a day – from the moment we open to the moment we close.”

Sponsored

Non-invasive vaginal rejuvenation is now a well-established and popular procedure to treat a variety of vulvovaginal disorders, improve sexual gratification and enhance the aesthetic appearance of the external female genitalia. This rejuvenation is accomplished via neocollagenesis, neovascularization and possibly neoneurogenesis.

While other CO2 laser devices on the market use ablative fractional resurfacing, Lasering USA (San Ramon, Calif.) recently launched a new, non-ablative/non-fractional CO2 laser-based device for feminine rejuvenation called V-Lase®, which uses their patented chopped CW technology.

Gentle heat from the non-ablative laser beam creates mild thermal damage to the mucosal lining and underlying tissues of the vaginal canal and vulva. This will remodel (shrink and tighten) existing collagen and induce fibroblasts to undergo mitosis and replicate, thus creating new collagen, elastin, reticular fibers and glycosaminoglycans (GAGs) in the extracellular matrix.

All of this activity will thicken, tighten and make the vaginal walls more elastic and pliable over time (reducing the vaginal canal diameter for better sensation during intercourse). It will also create new superficial blood vessels that not only provide better oxygenation and nutrition to the tissue, but also increases vaginal transudate, which helps restore vaginal moisture and pH balance. This will decrease vaginal itching and burning, reduce symptoms of painful intercourse, lower the risk of vaginal infections, strengthen the pelvic floor to improve symptoms of stress urinary incontinence (SUI) and increase neurogenesis, which improves G-spot nerve sensitivity to heighten sexual gratification.

V-Lase offers many benefits over ablative modalities. Since it does not invade the surface tissue, there is no risk of worsening or initiating an infection. There is no bruising and no production of discharge, therefore there is no downtime from sexual activity, exercise (including swimming), or the use of tampons if treatment is performed in proximity of a menstrual cycle. 

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. There are over 100 types, some of which can lead to numerous forms of cancer. It is estimated that up to 80% of all females will contract HPV at some point during their life. When using an ablative CO2 laser for vaginal rejuvenation on a patient who is currently infected with HPV there is an elevated risk of spreading or worsening the infection in that patient, as well as a risk of HPV contamination to the medical practitioner and/or support staff assisting in the procedure.

Furthermore, ablative CO2 lasers create a smoke plume, which is a natural consequence of ablation. As a non-ablative system V-Lase does not require the use (or added expense) of a smoke evacuator.

Other benefits of non-ablative vaginal rejuvenation include no need for topical anesthetic due to less patient discomfort during treatment, and the low intensity of non-ablative CO2 laser light does not require shaving of the external genitalia when treating the vulva. Also, the V-Lase device has no consumables as the probe, insertion ring and external handpiece can be steam sterilized.

Editor's Note:

Dr. Menchaca is fellowship trained in female pelvic medicine and reconstructive surgery. He has been using the CO2 laser for medical, surgical and cosmetic procedures since 1983. Dr. Menchaca has performed thousands of pelvic reconstructions with native tissue, graft and synthetic mesh and is the director of Female Pelvic Medicine & Reconstructive Surgery at Paris Community Hospital in Paris, Ill. Dr. Menchaca has lectured extensively on pelvic reconstruction and trained hundreds of surgeons on his techniques in the operating suite.

Sponsored

From fine lines and photo-aging, to stretch marks and scars, the Secret RF by Cutera (Brisbane, Calif.) offers something for just about everyone. By combining radiofrequency (RF) energy, semi- and non-insultated microneedles, and adjustable depths of needle penetration, physicians can customize treatments based on each patient’s individual concern, skin type, and/or body area.

“I’ve used most of the RF microneedling (RFMN) devices on the market,” said Arash Moradzadeh, M.D., a facial plastic surgeon based in Beverly Hills, Calif. “I chose Secret RF because it is the most versatile – you can adjust your settings to treat a variety of conditions.”

In Dr. Moradzadeh’s experience, the typical RFMN device is very good at treating acne scars or deep wrinkles. But with
Secret RF, “Due to the dialable penetration, we now have one machine that can treat a very broad range of issues, from acne scars in a 20-year-old to crepey skin or wrinkles in a 70-year-old,” he expressed.

The thin skin of the forehead and eyelids requires shallow penetration, versus the thicker skin of the cheeks and body, Dr. Moradzadeh pointed out. “Flexibility is critical in treating acne scarring as pitting requires deep penetration, followed by a shallow application to smooth the skin’s surface.” 

Treatment begins with topical anesthetic cream applied for 30 to 40 minutes. For acne scars, “I deliver two passes at various depths, depending on the severity, to ensure that the energy is being delivered where it is most effective,” Dr. Moradzadeh shared. “With Secret RF, you’re producing a layered approach. Each patient will receive a customized treatment that is very specific to their needs, skin and goals.”

Additionally, adjusting energy levels allows Dr. Moradzadeh to provide more significant results in one session, if that is what the patient desires. “Or you can choose a gentler setting for light rejuvenation, fine lines or pores. I am able to dial down the energy level, making it a very comfortable treatment with very rapid recovery,” he advised.

Dr. Moradzadeh typically uses the 25-pin non-insulated applicator for general rejuvenation on lighter skin types. “The 25-pin semi-insulated needle will work on all skin colors as the insulation protects the surface of the skin, allowing more energy to be delivered at the tip of the needle,” he explained. In addition, the 64-pin semi-insulated applicator covers a larger surface area for body treatments.

“These smooth microneedles, which are controlled by a motorized handpiece, gently penetrate into the skin, delivering RF or heat into the epidermal and dermal layers, depending on the depth you determine,” Dr. Moradzadeh indicated. This causes a calculated injury to the tissues, eliciting a healing reaction that returns elastin, hyaluronic acid and collagen – key components of youthful skin – to the treated area.

A typical course of treatment includes three to four applications delivered every four to six weeks. Patients start seeing better, brighter skin in about two weeks, while collagen building takes six months. “Most patients are very happy with their results about two months after their second treatment. They see very significant changes,” Dr. Moradzadeh reported.

Sponsored 

The multi-wavelength ADVATx platform from Advalight (Copenhagen, Denmark), provides outstanding results for vascular lesions without consumables or need for cooling via its 589 nm wavelength. And with the addition of the 1319 nm wavelength, ADVATx can treat a wide variety of common aesthetic indications safely and effectively, increasing versatility and ROI.

“With a similar wavelength; no need for liquid dye for the laser; or cooling during treatment, ADVATx is the next-generation alternative to the pulsed dye laser,” explained dermatologist David J. Goldberg, M.D., J.D., medical director of Skin & Laser Surgery Specialists of NY & NJ (with offices in New York City, New Jersey and Florida).

“We’ve known for three decades that the ideal wavelength range for treating vascular lesions lies between 585 nm and 595 nm, which provides clinically relevant absorption and depth of penetration for those indications,” Dr. Goldberg noted. “With this we’ve grown used to seeing purpura, needing cooling and replacing toxic dyes. However, because of ADVATx’s unique scanning system, which features several different sizes and patterns, scanning of larger areas is enabled, thus the laser is never dwelling too long on any one area. And it delivers enough energy for the desired clinical outcome.

“A course of treatment for a given condition will be about the same as with a pulsed dye laser: three to five for facial erythema; two to three for telangiectasia; and so on,” he added. “ADVATx gives us the utility of a pulsed dye laser without the associated untoward effects and expense.”

The clinical results are excellent. “In the years I’ve treated vascular lesions I’ve seen everything,” Dr. Goldberg said, “and I’ve now come to rely on the impact of ADVATx on vascular lesions, even port-wine stains, red scars, stretch marks and telangiectasia. Discomfort is minimal so I rarely need to use topical numbing cream. With a typical course of treatment, the patient will probably notice improvement after the second session. In fact, we have a paper that’s been accepted for presentation at the upcoming American Society for Laser Medicine & Surgery (ASLMS) annual meeting on treating facial erythema with this device.”

According to Dr. Goldberg, the system is easy to operate and features user-friendly presets that make treatment a breeze. “With my experience I don’t rely on the presets, but they are excellent, accurate and very easy to use for the beginner. It breaks things down by skin type and the condition to be treated.”

“The inclusion of the 1319 nm wavelength adds utility and improves ROI,” he shared. “You can use it for acne, acne scarring, skin toning and more, all without disposables, which really makes ADVATx a valuable device to have in my practice.” It is also remarkably reliable. “Because it is solid-state and requires no consumables, ADVATx is relatively inexpensive to run. We’ve had it for more than a year and it never breaks down.”

“What it boils down to is that we have a tried and true, proven wavelength in ADVATx delivered in a manner that’s more effective overall. It provides the great results we’ve come to expect when treating vascular lesions, but with minimal to no discomfort, and the added utility of the 1319 nm wavelength, with no consumables or cooling.”

Most of 22 studies in a recent review suggest positive results from platelet-rich plasma (PRP) treatment for androgenic alopecia, facial skin aging, fat grafting and acne scarring. 

But big questions remain. The studies in the systematic review lack standard PRP preparation protocols, application methods and standardized objective assessments of skin quality before and after PRP treatment. Existing studies looking at PRP for facial aesthetics and alopecia don’t tend to have control groups, and collectively don’t offer clear information about how many treatments are needed or how long PRP’s effects last, according to the review in the May issue ofPlastic and Reconstructive Surgery.

The evidence supporting PRP appears strongest among the six studies, including 84 total patients, looking at PRP to treat androgenic alopecia. A mean volume of 22.6 mL of whole blood was collected from subjects in the six studies. Three studies reported on the volume of PRP prepared from the whole blood, which was a mean 8 mL of PRP harvested per session. Three studies reported using multiple injections in a linear pattern, about 1 cm apart, a technique called nappage. And in most studies, researchers performed four treatments, ranging from once weekly to once monthly. Researchers reported substantial hair growth in all but one of the studies. The one study still showed improved patient satisfaction from the treatment. 

All of the 14 studies evaluating use of PRP for facial rejuvenation reported positive aesthetic outcomes — whether researchers used PRP alone or with fat grafting. Researchers in four of seven studies looking at PRP alone performed three treatments, total, once every two to four weeks. In the remaining three studies, researchers performed one PRP treatment. Other findings: Researchers used a mean 2.7 mL for each treatment in the seven studies. And while application sites varied, the most commonly injected were the infraorbital area, nasolabial folds and crow’s feet. Reported benefits from PRP treatment on the face were improvements in the volume, texture and tone, as well as decreased appearance of wrinkles.

Seven studies, including 437 patients, evaluated PRP-assisted fat grafting. Six of those offer detailed methodology on PRP preparation, including collecting a mean 35.7 mL of whole blood, which yielded a mean 5.2 mL of PRP. Based on five studies, the ratio of fat to PRP used in each procedure ranged from 2:1 to 10:1, with a mean ratio of 5.8 mL of fat to 1 mL of PRP. While the nasolabial folds and malar regions were most commonly injected, authors also injected cheekbones and the temporal region.

Two studies, representing 57 patients, found positive results with the use of PRP to treat facial acne scars. Researchers injected PRP intradermally into atrophic skin scars or used PRP in conjunction with microneedling.

The good news for now is PRP treatment for facial aesthetics and hair loss appears safe. Concerns about what might happen should high-density platelet solution get into a vessel haven’t panned out as a complication in any of studies in the authors’ literature search.

"To date, the question of whether PRP’s cocktail of growth factors generates a more youthful appearance has not been definitively answered," the researchers write.
More formal randomized, controlled trials studying the use of PRP in facial cosmetic procedures are needed, according to the review.

Of the 9 million patients in the United States who have had dermal fillers, an estimated 8 million are experiencing “filler fatigue,” according to a new survey conducted by The Harris Poll.

The patient survey also found that 58% of users note frustration and hassle in scheduling regular appointments, and two in three users claim that their current fillers do not last as long as their previous fillers.

The cost of ongoing maintenance was cited as the top reason (56%) why patients do not schedule filler sessions as often as they would like.

On the other hand, 91% of respondents believe that a five-year filler would be innovative and important to them. Additionally, a full 88% feel a five-year filler is unique.

In fact, lengthening the duration of a filler was the number one improvement mentioned.

“There were a couple parts of the data that were surprising,” says Patricia Altavilla, vice president of sales and marketing for Suneva Medical Inc. (San Diego), which commissioned the survey. “First, is the number of men that have had dermal fillers. We were certain that this part of the market was growing; however, 4 million was a bigger number than anticipated.”

Altavilla also tells The Aesthetic Channel that she finds it surprising that “82% of filler patients reported a likelihood to change providers if their current provider did not offer a five-year filler.”

Similarly, when current providers offered Suneva’s five-year Bellafill filler to their patients, 88% of patients said they would likely continue seeing their provider for other types of aesthetic procedures that they had yet to experience.

The survey is follow-up to 2016 research by Suneva that was undertaken “to take the initial temperature of the consumer market toward a 5-year filler and validate our thinking about positioning of the brand,” Altavilla says. “The Harris Poll was for a trending read 18 months later and to size the market.”

And while there are no medical/clinical ramifications of the current survey, “it does demonstrate the significant changes in the aesthetic market and the impact of the broadening new offerings in the market,” Altavilla observes. “These offerings have caused patients to evaluate how and on what they spend their money. The desire for a long-lasting filler is most certainly stimulated by the desire to access the many other aesthetic treatments and solutions. “

Altavilla says The Harris Poll data reflects the dynamic changes in the aesthetic market. “The availability of a five-year filler is reshaping the dermal filler market,” she says. “The future of aesthetic medicine needs to be focused on longer lasting outcomes, as patients’ desire to have full access to all treatments to maintain their aesthetic outcomes.”

On May 21, the FDA approved the hyaluronic acid (HA) dermal filler Restylane Lyft (Nestlé Skin Health) to correct age-related volume loss on backs of the hands. It’s the first FDA approval for an HA dermal filler off the face.

But it’s not the first dermal filler approved for cosmetic treatment of the hands. Synthetic calcium hydroxylapatite dermal filler Radiesse (Merz Aesthetics) was approved in 2015 for hand augmentation to correct volume loss in the dorsum of the hands, according to the FDA.

Restylane Lyft has been on the market for more than a decade. It’s also FDA approved for the midface/cheek area and nasolabial folds.
The latest FDA approval was based on a multi-center, randomized, evaluator-blinded, split-hand study, including 89 patients, ages 22 and older. Investigators studied Restylane Lyft’s safety and efficacy, reporting a clinically meaningful improvement in the correction of volume deficits of treated hands for up to six months. Restylane Lyft with Lidocaine is indicated for injection into the subcutaneous plane in the dorsal hand to correct volume deficit in patients older than 21.

Injection site swelling, tenderness, redness, bruising, pain, itching as well as impaired hand function were, for the most part, mild and transient, according to a press release by Nestlé Skin Health.

NEXT: 10 Tips for Better Outcomes

Ellen Marmur, M.D., a dermatologist in New York City and clinical trial investigator for Restylane Lyft for hands, offers the following tips to The Aesthetic Channel readers for optimal outcomes.

For the Patient:

1. Ask the patient which areas are their top priorities. You'd be surprised — sometimes it's the valleys between the tendons, sometimes it is the prominent vessels specifically in one area that they are most focused on.

2. Advise the patient to hydrate well.

3. Advise the patient to stop all vitamin supplements, ibuprofen, other anti-coagulants, and no booze the night before — to avoid bruising.

4. Advise the patient to avoid hand intensive exercises for 1-2 days afterwards including cycling, tennis, and yoga — to prevent swelling.

5. Show them how to elevate their hand and elbow for a few minutes several times a day for 2-3 days if needed for swelling.

For Technique:

1. Evaluate volume loss and consider average use might be more than one syringe per side — counsel the patient in advance.

2. Cleanse well and prime the syringe of air before injection.

3. Tent the skin and lift away from the underlying anatomy.

4. Insert the needle facing the wrist at the distal hand at an acute angle between the skin and the underlying anatomy and inject in retrograde threads.

5. Spread the filler evenly with medium pressure.