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Experts discuss advanced energy-based face-lifting solutions

Article-Experts discuss advanced energy-based face-lifting solutions

energy-based treatments, non-surgical face-lift, lasers, RF microneedling,

Whether consumers scrutinize their images in selfies, social media or the rearview mirror, they're more intent than ever to rid their faces and necklines of the tell-tale signs that time isn't on their sides. Coupled with this desire to fight aesthetic aging is a rising demand for noticeable cosmetic outcomes without downtime, drugs, foreign substances or surgery.

The result is a surge in energy-based devices aimed at tightening, lifting, toning and firming the face and neck, diminishing wrinkles and encouraging collagen production.

Global statistics show demand of energy-based and other minimally invasive cosmetic surgery options is widespread. RealSelf, a worldwide online community for consumers seeking cosmetic procedures, reports facial lasers are gaining traction, according to RealSelf’s U.S. Laser and Energy Report released in July 2018. This report showed that consumer interest in treatments using laser and energy-based devices grew 10.5% in 2017 compared to the prior year.

The power of, and momentum behind, energy-based facial rejuvenation is more than hype. Today’s improved safety and efficacy make these viable options for an expanded patient base, researchers reported in a review published in 2017 in JAMA Facial Plastic Surgery1.

According to the JAMA papers, non-surgical facial rejuvenation technology has rapidly expanded over the past five years, with the focus of this technology shifting to carefully balance minimal risks and downtime with maximized outcomes.1

Furthermore, non-surgical skin tightening is best suited to patients with mild to moderate skin laxity and photoaging, or extrinsic aging, without significant underlying structural ptosis.1

In this respect, it is important that physicians who use today’s energy-based technologies are clear with patients about what the devices can and cannot do, noted Koenraad De Boulle, M.D., a dermatologist and director of a dermatology and derm-surgery clinic in Brussels, Belgium.

“Lasers, for example, can tighten skin, reduce wrinkles and encourage collagen formation, but they cannot lift skin, Dr. De Boulle indicated.

Technically, true lifting of the skin is a vertical lift, which classic facelifts achieve. The tightening that results from energy-based technologies happens in all directions. For patients who need facial skin lifting, energy-based technologies can play an adjunctive role, improving overall results from surgical procedures, he said.

Jennifer Walden, M.D., a plastic surgeon with a practice in Austin, Texas, and a medspa in New York City, N.Y., compares the rapidly evolving landscape of energy-based treatments focused on facial rejuvenation to what’s happening with body shaping / fat reduction devices.

“Every year we have upgraded modalities, better results and improvement in pain associated with these procedures,” Dr. Walden said.

While results from energy-based devices are less dramatic than those from surgery, Bettina Rümmelein, M.D., a dermatologist who practices at the House of Skin and Laser Medicine in Zurich, Switzerland, and trains physicians in aesthetic laser use, said demand is strong because patients tend to prefer non-invasive treatments and are willing to accept limited results.

To achieve optimal results, Dr. Rümmelein often uses devices in combination.

“Different devices reach different layers of the skin. They all have their own characteristics and stimulate the skin in a different manner,” she said.

For facial skin tightening, Dr. Walden’s preferred laser is either the erbium or fractionated CO2 laser, which she said tightens nicely with minimal downtime.

Similarly, Sabrina Fabi, M.D., a cosmetic dermatologist and assistant clinical professor at the University of California, San Diego (San Diego, Calif.), said the gold standard for facial skin tightening remains the fully ablative CO2 laser.

Dr. Fabi, who uses the UltraPulse by Lumenis (San Jose, Calif.), said studies show that CO2 treatment can result in up to 40% skin contraction by vaporizing tissue and delivering heat to stimulate new collagen production. Specifically, UltraPulse can penetrate deeper than many other ablative CO2 lasers, offering the versatility needed to make it an option for everyday procedures, as well as thick and complex lesions.

“No other device really vaporizes tissue,” Dr. Fabi added. “I feel UltraPulse is the most powerful CO2 laser in aesthetic medicine. As such, it is an ideal option for patients in California who tend to have a lot of static wrinkles and infraorbital crepey, lax skin in need of tightening.”

Dr. Rümmelein said the CO2 fractional laser eCO2 from Lutronic (Boston, Massachusetts, U.S.), in combination with platelet-rich plasma (PRP), is among her gold-standard approaches for facial wrinkle reduction, tightening and collagen creation. She also uses a combination approach when treating only the eye region.

“I use laser-supported photodynamic therapy (PDT) with the eCO2,” said Dr. Rümmelein, who has more than 40 energy-based devices at her clinic.

For patients who have actinic damage requiring removal of the entire skin surface, and more dramatic improvement in facial rhytides, Dr. Rümmelein uses laser-supported PDT with the eCO2 in low doses. She applies Metvix from Galderma (La Defense Cedex, France), a topical photosensitizer containing 16% methyl aminolevulinate, in cases of severe actinic damage.

“Oftentimes patients who undergo surgical facelifting procedures have cracks, rhytides and crevices in their skin. The traditional facelift isn’t going to fix that,” Dr. Walden said. “I can inject fat in the temple area, in the nasolabial folds, lips and mental crease, but for all the superficial rhytides I need a laser resurfacing procedure. If I resurface in conjunction with a surgical facelift, I can deliver a better result.”

Along these lines, a technology favorite for Miriam Emily Piansay-Soriano, M.D., a professor and chairman in the department of dermatology at Davao Medical School Foundation, president and medical director of MediSkin, and dermatology and dermatologic surgery consultant at Davao Doctors Hospital (Davao City, Philippines), is the HarmonyPro platform from Alma Lasers with multiple handpieces.

“In my opinion, the PIXEL Erbium:YAG handpiece is the best for skin resurfacing in Asians because it rarely results in the post-inflammatory hyper- or hypopigmentation (PIH) that we almost always see when resurfacing type IV skin with CO2 lasers,” Dr. Soriano said.

For patients at risk of developing PIH, Dr. Fabi may use the fractionated CO2 Fraxel Repair from Solta Medical, a division of Bausch Health Companies (Bothell, Wash.), to improve more superficial skin laxity; however, it still leaves patients with seven days of downtime.

Other options among fractional resurfacing lasers are the ablative CO2-based MiXto SX and Pro by Lasering USA (San Ramon, Calif.). These systems reportedly achieve unparalleled facial rejuvenation via two patented technologies. First, a unique laser operating mode called Chopped CW deposits a higher level of thermal damage to the dermis for greater collagen production and skin tightening. Second, a Z-shaped mathematical algorithm scan pattern reduces heat build-up between adjacent laser spots, which decreases patient discomfort during treatment and lowers the risk of adverse events post-operatively.

A limitation of using the CO2 laser is that it requires downtime, Dr. Fabi pointed out. “When you deliver that kind of heat, you’re going to be left with about seven to ten days of ruddy, crusty redness. That doesn’t fit into the lives of many people,” she said.

Laser companies continue to develop technologies aimed at decreasing undesirable side effects.

The Youlaser MT from Quanta System (Samarate, Italy) offers a unique combination of CO2 and Er:Glass. This mixed technology combines ablative and non-ablative effects in sequential or simultaneous pulses and fractional patterns. Users can adjust the device to stimulate new collagen formation. Treatment of wrinkles, fine lines and loose skin can be performed with excellent results, especially on very delicate Asian skin, while preventing undesired side effects, according to the company.

Some lasers are carving a niche within the market. For example, the Fotona4D from Fotona (Slovenia) makes laser-based face lifting a reality via the SP Dynamis. Offering a unique combination of four distinct modes of aesthetic treatment, harnessed in concert to combat facial aging, both the exterior facial and interior oral cavity can be treated, enabling full-thickness contraction of collagen for persistent tightening and volumization without injectables. 

With two laser wavelengths (Er:YAG and Nd:YAG), the company says anti-aging is comprehensively approached from four different levels, working on deeper, medialand superficial connective structures of the skin, as well as targeting imperfections. Furthermore, Fotona4D is a popular application among patients because it not only offers effective anti-aging, but also because there is little or no downtime, no anesthesia and the procedure can be performed year-round.

Another option is the novel PICOCARE picosecond laser system from Wontech (Daejeon, Korea), which features dual wavelengths (532 nm and 1064 nm) and a variety of handpieces, including zoom, collimation, 595 nm, 660 nm, and HEXA MLA. In particular, the HEXA MLA fractional handpiece creates plasma-induced cavitation in the epidermis and/or dermis, which activates fibroblast and collagen synthesis without damaging the epithelium and basal membrane. Unlike conventional ablative fractional laser systems, HEXA MLA stimulates neocollagenesis and collagen remodeling via photomechanical effects rather than photothermal, resulting in lower incidence of thermal damage and other adverse effects. With a single treatment, rhytides, fine lines and wrinkles are improved.

When Michael H. Gold, M.D., medical director of Gold Skin Care Center and the Tennessee Clinical Research Center, in Nashville, Tenn., thinks of non-surgical, energy-based facial skin tightening, his go-to device categories are radiofrequency (RF) and ultrasound. “There are a lot of RF devices that achieve tightening,” Dr. Gold said.

RF devices are being used to not only tighten skin, but also reduce small areas of fat. 

Among the bulk heating RF devices in his practice are Alma’s Accent Prime, Endymed’s 3Deep, Venus Concept’s Legacy, BTL’s Exilis Ultra 360, Thermi’s ThermiSmooth, Syneron-Candela’s eMatrix and Solta’s Thermage.

“I think they all have a benefit,” stated Dr. Gold. “What I tell people about RF is every company has a story – a way that they deliver their energy a little bit differently than any of the others.” Another differentiator is whether devices are monopolar or bipolar. Thermi, Exilis and Thermage are monopolar; the rest are bipolar, he explained.

Monopolar devices are more powerful, so patient comfort can become an issue. But manufacturers are working on making monopolar treatments less painful.

Dr. Rümmelein uses the eTwo fractionated radiofrequency (RF) device from Candela (Irvine, California, U.S.), to treat skin types IV and V. One of the best indications for using the technology is to address loss of elasticity, she shared.

“I am very impressed by the results of RF technology on the skin,” Dr. Rümmelein said. “It can be used on all skin types. You really see significant differences with diminished nasolabial folds, reduced wrinkles, greater jawline definition and more. I use it for full-face elasticity loss, laxity and volume loss.”

Monopolar RF devices, such as Thermage, achieve a mild level of skin contraction, Dr. Fabi noted.

Thermage FLX from Solta Medical is a new FDA-cleared skin tightening solution that is uniquely indicated for periorbital (including eyelids) and full-facetreatments. Harnessing non-invasive RF energy and delivering it deeply within the dermis to tighten, remodel existing collagen and stimulate neocollagenesis, this system can be used on all skin types, and features patented AccuREP technology, a real-time feedback-controlled per-pulse adjustment of RF delivery that improves precision and predictability.

Thermi, an Almirall Company (Irving, Texas), has introduced the new ARVATI system, which features advanced temperature-controlled RF EPIC technology. Powered by ThermiRF, the ARVATI offers emission of continuous, powerful RF waves, with an enhanced 50 W capacity system, intelligent software with electrode recognition and a control algorithm, offering speed and control for various modalities, including ThermiTight, ThermiRase and ThermiSmooth Face.

RF and ultrasound devices are also joining the ranks of CoolSculpting from Allergan and SculpSure from Cynosure, a Hologic company, in their ability to sculpt areas around the neck or jawline.

truSculpt 3D, a noninvasive monopolar RF system from Cutera (Brisbane, California, U.S.), which is optimized to deliver targeted, repeatable and uniform sculpting of problem areas, including the neck, without visual downtime.

According to the manufacturer, truSculpt 3D takes a multi-dimensional approach to decrease circumference and permanently eliminate fat by delivering and holding clinically therapeutic temperatures to the subcutaneous adipose tissue to achieve the highest clinical efficacy in the shortest possible treatment time with enhanced safety and comfort.

EmbraceRF by InMode (Richmond Hill, Ontario, Canada), is another new option for addressing loose skin on the neck and jowls. This subdermal adipose remodeling device (SARD) utilizes minimally invasive RF and bipolar RF energy to contract skin, as well as improve textural and fat concerns. In addition, it can be used in combination with liposuction, depending on how much fat is in the treatment area.

Dr. Soriano has been observing a new Asian beauty trend in recent years.

“In the last five years, the trend has been to convert round chubby faces, which present a childlike appearance, to a more V-shaped face, which gives a more mature, sophisticated look,” Dr. Soriano said. “In my practice, this is best achieved with several sessions of unipolar radiofrequency treatments on the mandibular and submandibular areas of the face, in combination with toxin injections to the masseter.”

For Dr. Soriano, the Reshape RF from Alma Lasers is her favorite energy-based device for achieving dramatic, consistent and reproducible face reshaping, lifting, toning, firming and tightening.

It is important to note that providers and patients using bulk heating RF for facial rejuvenation should think in terms of multiple treatments, maintenance treatments and no downtime.

“My wife comes in and gets her eyes done with an RF device every three or four months. It takes 20 minutes, she’s done and doesn’t need anything else,” Dr. Gold said.

Dr. Gold and colleagues published a study using the Endymed 3Deep, showing lifting and tightening results similar to those experienced in research investigating the Ultherapy device from Merz Aesthetics (Raleigh, N.C.). “Using very high RF energies, we obtained nice tightening and showed lifting, comparatively,” Dr. Gold reported.

High intensity focused ultrasound (HIFU) energy is among the leading approaches that physicians worldwide use to lift and tighten the skin. Yu-Hao Huang, M.D., a plastic surgeon and director of the International Aesthetic Center in Kaohsiung City, Taiwan, uses the HIFU-based device Ultraformer, from Classys (Korea), for facial tightening and minimal lifting on Asian skin. The Ultraformer is designed to treat Asian skin types, as its parameters are based on clinical studies with Asian patients, Dr. Huang reported.

The Ultraformer III treats elasticity loss on the face, neck and décolletage, “and there’s no downtime for patients,” Dr. Rümmelein said. “HIFU results in micro-damages in several levels under the skin, which induces repair mechanisms.”

As the third version of the Doublo series from Hironic (Gyeonggi-do, South Korea), the Doublo Gold’s HIFU technology allows physicians to target the superficial musculoaponeurotic system (SMAS) and dermis without any incision or damage to surrounding tissue. By delivering thermal energy 3 mm to 4 mm into the skin, treatment regenerates collagen for skin tightening, while diminishing wrinkles and rejuvenating the face.

The SygmaLift by Medixsysteme (Ruggell, Liechtenstein) is another example of an energy-based system that has evolved to not only lift, but also contour and remodel the face. The synergism of the thermal and mechanical actions of focal ultrasound energy results in effective treatments that accentuate the neck and jawline, contour the eyes and lift the eyebrows.

With no surgery or incision required, SygmaLift is ideal for those who want firm and younger-looking skin. It is not just a facial lifting system, but also a facial remodeling option due to its ability to deliver energy to a depth of 5 mm. This creates safe warming of the targeted tissues non-invasively from the inside out, stimulating collagen and skin regeneration.

FDA-cleared to lift skin of the neck, non-surgical Ultherapy has been established as the go-to device for treatment of submental skin laxity, jawline laxity and jowls.

“Ultherapy is microfocused fractional ultrasound, it is very safe and there’s no question it works,” Dr. Gold stated. “You have to do it properly and control any discomfort, but Ulthera is usually just one treatment; two, rarely.”

In addition to Ultherapy, Dr. Fabi also uses ThermiRF primarily for the neck. “I like to reserve this for patients that have a little bit of fat because when you run the RF probe within adipose tissue you can obtain a little bit of fat destruction,” she said.

The key, according to Dr. Gold, is to determine whether patients’ submental fullness is from fat or skin laxity. If it is from fat, Dr. Gold uses CoolSculpting CoolMini or Kybella, both from Allergan (Irvine, Calif.); if the problem is skin laxity, he uses Ultherapy.

Dr. De Boulle addresses excessive submental fat in some patients with CoolSculpting’s Cool Mini from Allergan.

“CoolSculpting Mini for submental fat is perfect,” he said. “It is a reliable and standardized procedure. It will not do anything for the lines, but it will help in reducing submental fat and providing a tightening of the overall skin against the deeper tissue. So, the cervicomental angle will be better.”

SculpSure from Hologic, Inc. (Marlborough, Mass.) is another device that is FDA cleared to address the double chin. Application of this 1060 nm hyperthermic diode laser heats subcutaneous adipose tissue to disrupt fat cells, leaving extracellular lipids and cellular debris to be naturally removed by the body.

However, as Dr. De Boulle pointed out, excess fat isn’t the only concern people have with their necks. Patients often request treatment of the horizontal and vertical lines that may appear with age.

While Dr. De Boulle specified that a surgical neck lift is the leading solution to address horizonal bands, he said there is one exception – skin tightening, and he has achieved notable success in diminishing horizontal lines on the neck with RF microneedling.

“I think the Infini (Lutronic) is one device that I’ve seen that has a certain percentage of success in reducing these lines,” Dr. De Boulle denoted. “And unlike surgery, the advantage of RF microneedling is the minimal downtime, which is not dramatic. Patients have a couple of days of scabs and redness.”

Conversely, none of today’s devices will treat the vertical lines on the neck – the “platysmal bands.” These are best treated with neuromodulators, Dr. De Boulle added.

While energy-based devices don’t volumize in the way that traditional injectable fillers do, they can thicken the dermis by stimulating collagen production, Dr. Fabi explained.

Roy G. Geronemus, M.D., director of the Laser & Skin Surgery Center of New York and clinical professor of dermatology, New York University Medical Center, said his go-to devices for collagen formation include non-ablative and ablative fractional devices, such as Lutronic’s LaseMD, Valeant’s Clear + Brilliant, Fraxel Dual or Fraxel Repair, as well as Sciton’s Halo hybrid fractional laser.

Some devices combine RF with microneedling. These systems are among the energy-based technologies that encourage collagen production.

In Dr. Rümmelein’s experience, the single best device for facial aging is RF microneedling with Infini.

Infini delivers RF energy via insulated needles at varying customizable depths. The insulation protects the epidermis from electrothermal damage, which reduces downtime and risk of post-inflammatory hyperpigmentation (PIH), while heating the deeper tissues to achieve coagulation. Research has shown that heating the dermis to a high enough temperature will cause collagen coagulation, which results in neocollagenesis and neoelastinogenesis. During this remodeling process, new collagen gradually replaces the old, leading to skin tightening.

According to Dr. Gold, RF microneedling offers patient benefits with a few drawbacks.

“Microneedling with RF is a little more invasive because of the needles so there’s more pain,” he elaborated. “But patients need fewer treatments. Maintenance is often pushed out about a year in most cases. And you achieve good tightening and a nice lift.”

Dr. Gold’s go-to options in this category are: Endymed’s Intensif, Lutronic’s Infini, InMode’s Fractora, Venus Legacy’s Viva and Jeisys Medical’s INTRACel (distributed in the U.S. by Perigee Medical).

Dr. De Boulle also favors RF microneedling with the Infini to address facial skin aging concerns, including skin tightening.

“When you apply the Infini, the RF current passes through a needle cushion of 7 by 7 gold-coated needles at different depths and different passes,” he stated. “This causes the collagen fiber bundles to shrink in all directions. We use the Infini as adjunctive therapy.”

Dr. Walden recommends RF microneedling to improve facial texture and for mild to moderate firming or tightening.

“I would advise doing treatments on a regular basis, so every three to four months for maintenance,” she said.

Recently, Dr. Walden opted for the Vivace device from Aesthetics Biomedical (Phoenix, Ariz.) for her medspa. This system uniquely features not only RF microneedling, but also LED technology for pigment.

“It is a combination treatment in one device,” she stated. Vivace provides a minimally invasive treatment that stimulates the natural production of collagen and is shown to be effective in alleviating facial wrinkles and fine lines, as well as tightening and toning the face and neck. The results are immediate and also improve over time, giving patients the best of both worlds.

Other RF microneedling systems include the recently FDA approved PiXel8-RF from Rohrer Aesthetics (Homewood, Ala.). Using bipolar RF, which is safe for all skin types, alongside minimally invasive insulated or non-insulated microneedles, the PiXel8-RF facilitates non-surgical skin tightening. During treatment, heat is driven deep within the skin layers to stimulate collagen and cause elastin cells to regenerate, resulting in a firmer, smoother and more consistent skin surface.

Cutera’s Secret RF is another novel fractional RF microneedling system designed to stimulate and remodel collagen, and address the common signs of aging. By adjusting the microneedles, Secret RF can deliver energy at various depths so that treatments can be tailored to deal with each patient’s individual concerns, such as fine lines and wrinkles.

The Legend Pro from Lumenis uniquely features RF assist microneedling and Tripollar RF. By delivering RF energy via three or more electrodes, treatment induces controlled heating of the deep dermis, initiating collagen and elastin fiber regeneration.

Profound from Syneron Candela (Wayland, Mass.) is a bipolar RF system that utilizes five pairs of microneedle electrodes to deliver fractionated thermal injuries in the deep reticular dermis where the concentration of collagen is the highest. This thermal injury stimulates dermal remodeling and new elastin, collagen and hyaluronic acid formation. Study findings show a 100% response rate for rhytides and 95% response rate for laxity at six months post-treatment. Profound can be used to restore dermal volume loss, treat nasolabial and melolabial folds, jowls, submental and submandibular redundancy.

Dermatrix Duo from GSD (Shenzhen, Guangdong, China) combines microneedle and needle-free fractional RF technology for skin resurfacing, wrinkle reduction, skin tightening and more. In a controlled manner, the microneedle handpiece can penetrate deep into different skin layers, while the needle-free handpiece acts on more superficial areas. And as a non-laser technology, treatment is safe for all skin types, even darker, pigmented patients.

While there are contrasting attitudes and beliefs surrounding microneedling, in Dr. Gold’s opinion, “Suboptimal outcomes might result from not using sufficient energy or doing enough treatments, but ample studies have been done that show if you use RF needles properly, you can attain incredible results.”

Dr. Geronemus recently published case reports in Plastic and Reconstructive Surgery illustrating his use of the Infini high-intensity focused RF microneedling device to treat festoons.2

“Historically, these fluid-filled pouches on the upper malar portion of the cheek have been very difficult to remove. Over the years, physicians have tried surgery, ablative lasers and even injecting tetracycline in the malar pouches with minimal success,” Dr. Geronemus said. “We’ve had considerable benefit with a mildly invasive technique utilizing RF microneedling.”

Notably, today’s options go beyond laser and RF and ultrasound technologies. Acoustic Wave Treatment (AWT) from STORZ MEDICAL (Tägerwilen, Switzerland) features the D-ACTOR Ultra handpiece, which uses shock waves as pulsating acoustic waves to non-invasively diminish fine lines and wrinkles.

During AWT treatment, acoustic waves are gently introduced through the skin’s surface, stimulating fibroblasts deep within the skin to initiate collagen and elastin production and promote cell renewal to improve skin density and elasticity, making the skin look firmer and smoother.

Hironic (Gyeonggi-do, South Korea) has introduced a new and unique device based on plasma and ultrasonic technology. PLASONIC is a solution-delivery technology that uses plasma (PlaPass) and ultrasonic (SonoPass) modalities in one system to emit plasma ions – which are invisible to the eye – that transfer energy into the skin. As the cell adhesion molecules break, due to the plasma effect, the solution is dissolved into the skin temporarily. Then SonoPass applies physical pressure on the particles and helps them to absorb into the deep skin layer. With this technology, users are able to provide a wide range of customized premium programs for various indications, including wrinkles.

When it comes to best practices in energy-based face lifting it is important that providers who recommend devices for lifting, tightening and rejuvenating facial skin make sure patients have realistic expectations.

“If someone has significant laxity, they’re better off with surgical management. Physicians need to be honest and forthright with patients about expectations and outcomes,” said Dr. Geronemus.

Furthermore, when it comes to energy-based aesthetic medicine, it is not only the device, but also the operator, Dr. Walden noted. “Employ people who have the certifications and experience with the devices in your practice to be able to handle them effectively and safely,” she expressed.

“Once we start breaking the integrity of the skin, energy-based devices are dangerous if they are not in the right hands,” Dr. Walden continued. “That includes the physician performing the procedure in the operating room, the nurse practitioner, physician assistant or the certified laser technician who is an aesthetician. The practitioner has to employ the right people to do these treatments, those who have the correct knowledge base for the proper settings and know the medical history of the patient.”

Notably, studies are also revealing best practices for energy-based facial rejuvenation. For example, providers who use fully ablative CO2 lasers for facial skin tightening should consider making only one pass with the device as research has shown that performing multiple passes increases the patient’s risk of developing delayed hypopigmentation, Dr. Fabi shared.

In addition, “If someone has had a blepharoplasty, it is important to know that history and perhaps decrease your settings during a fully ablative COtreatment in order to minimize the occurrence of an ectropion,” Dr. Fabi said.

Also, older patients with heavier laxity along the jawline or submental skin might have bone or structural loss, Dr. Fabi continued. “Those patients often benefit not only from ultrasound-based skin tightening, but also use of a filler in the midface or jawline to help support the repositioned tissue,” she said.

Dr. Soriano feels it is important to buy devices from distributors that are known for reliable after-sale service and recommends that aesthetic physicians choose energy-based devices that are user-friendly, with pre-set parameters for simplicity and ease of use. She also says that using the right device for the right patient is important.

“When you own many devices, you might not be able to remember all the parameters, which vary from one device to another,” she said.

“If you buy devices with no pre-set parameters, start low and go slow with the energies or fluences you are using. Then slowly increase fluence with each successive treatment of the same patient, until you find the optimum parameters that give you the best aesthetic results,” Dr. Soriano continued. “Try to stick to these parameters that are based on your experience, rather than following the accompanying manuals like a cookbook. Even in cooking, we always have to modify the recipes based on our taste!”

“There is a thin line between a successful result and a complication like fat atrophy with RF treatments, or PIH with fractional CO2 laser resurfacing – especially due to patient variability, differences in environmental (sun) exposure, and variations in post-procedural skincare,” she said. “Nevertheless, working with great devices and producing great results gives every physician and patient great satisfaction.”

“While energy-based devices might not yet mimic results from a surgical facelift, outcomes from lasers, RF, ultrasound and more, have come a long way,” Dr. Gold stated. “The science now is following the hype.”


Asian countries are among those leading today’s rapidly escalating worldwide demand for surgical and non-surgical cosmetic procedures. While North America has consistently led the global cosmetic surgery market, dominance is shifting towards Asia, particularly in the energy-based devices segment, according to the Global Cosmetic Surgery & Services Market Analysis 2015-2019 report.

Japan and India are among the top 10 countries worldwide that account for the bulk of cosmetic procedures performed today, as reported in statistics released by the International Society of Aesthetic Plastic Surgery (ISAPS) in 2017 – the most recent year for which information is available.

While achieving cultural beauty ideals in Asian countries might involve skull-altering surgeries to change the shape of chins and jawlines, rhinoplasty to redefine the nose or blepharoplasty to alter the contour of the eyes, not everyone has the time, money, desire, or is a candidate for invasive surgeries. Instead, many turn to less invasive energy-based skin lifting, tightening, contouring, collagen boosting and wrinkle reducing alternatives.

As demand for non-surgical treatments grows, researchers are reporting improved outcomes from a growing arsenal of energy-based device options, including radiofrequency (RF), RF microneedling, CO2, fractional, ultrasound and others.

According to Dr. Huang, the most popular energy-based facial procedure at his practice is laser therapy. While many women and men want more dramatic results from cosmetic surgeries like facelifts, many others – especially those who work – opt for procedures that require less downtime, he shared.

“There are quite a few working women asking for annual non-invasive procedures with energy-based devices because they can return to work just one to two days after being treated,” Dr. Huang said.

He estimated that 30% to 40% of patients coming to him for surgical lifting procedures, ultimately end up choosing energy-based technologies.

“In my mind, the best candidates for energy-based lifting are those asking for minimal improvement and those who don’t want their friends to know they are coming for cosmetic procedures,” Dr. Huang said. “Most of these patients would prefer almost no downtime, and they can afford the budget of annual maintenance procedures instead of changing their face in one surgery.”

Nevertheless, energy-based face lifting isn’t ideal for patients who want dramatic changes or others who have extremely loose skin, he added.

Based on demographics data, Dr. Soriano says, cosmetic patients in the Philippines tend to be younger than those in Western countries, as the average age in the Philippines for men is 23 years and 24 years for women.4

“Most of the patients coming to our dermatology clinics for aesthetic enhancements lie between the ages of 25 to 40 years old and do not have a whole lot of disposable income,” she said. “These are mostly patients still in the workforce who have allotted a part of their salaries for beauty maintenance, which has notably become a perceived necessity to achieve success in one’s professional or personal life.”

1. Britt CJ, Marcus B. Energy-Based Facial Rejuvenation Advances in Diagnosis and Treatment. JAMA Facial Plast Surg. 2017;19(1):64–71. doi:10.1001/jamafacial.2016.1435

2. Jeon H, Geronemus RG. Successful Noninvasive Treatment of Festoons. Plast Reconstr Surg. 2018 Jun;141(6):977e-978e. doi: 10.1097/PRS.0000000000004400.

3. Demand for Cosmetic Surgery Procedures Around the World Continues to Skyrocket [news release]. New York: ISAPS; June 27, 2017.

4. Index Mundi: Philippines Demographics Profile 2018. LOCATION: CIA World Factbook; 2018.