Sponsored by BTL Aesthetics
When injectable neurotoxin for glabellar lines exploded onto the market at the turn of the century, it blew the doors to aesthetic medicine wide open. Not only is the therapy safe and efficacious, but it also has a price point that makes it widely accessible to men and women worldwide.
According to a 2022 consensus paper,1 injectable neurotoxin is the most frequently performed aesthetic procedure and has an ever-increasing number of aesthetic and medical applications. However, 
decades of experience have revealed a catch: with time, sometimes for unknown reasons, patients may become resistant to neurotoxin effects. Long-term data is scarce, but increasingly patients require more units of toxin to achieve desired results. Recent observations suggest that an evolutionary approach to addressing the impact of neurotoxin resistance may benefit from the complementary use of high-intensity facial stimulation (HIFES™) brand technology and synchronized radiofrequency.
Facial aging has often been looked at as a skin issue but, in reality, there is much more contributing to it. Skin, fatty layers, facial muscles, connective tissue and bone, all age independently2 and vary based on genetics, environmental exposure and lifestyle. Emface® by BTL Aesthetics (Boston, Mass.) provides a multifactorial approach to the multifactorial nature of facial aging. “We lose muscle mass as we age, which accelerates in our later years. In addition to changes due to aging, regular use of injectable 
neurotoxin may theoretically accelerate this aging process by contributing to muscle atrophy, because we are effectively inhibiting muscle contraction via deactivation of key localized enervation with neurotoxin,” said facial plastic surgeon Yael Halaas, MD (New York, N.Y.). “So Emface is not only an effective treatment for the appearance of facial aging, but it also addresses the causes as much as the symptoms by restoring the musculature and support.”
Emface features BTL’s signature Synchronized RF with HIFES brand technology. “The HIFES component selectively stimulates elevator muscles to revitalize facial musculature and structure,” shared Amanda Holden, MD, founder and medical director of Holden Timeless Beauty in San Diego, Calif. “Concurrently, the Synchronized RF stimulates collagen and elastin while improving local microcirculation. This serves to tone, rather than enlarge, facial muscle and improve the skin as well, and there is a synergy between the modalities. This unique technology restores facial topography to a more youthful and functional state.”
In a recent study3 of 47 patients from four trials, computer-generated three-dimensional (3D) analysis revealed that Emface can favorably change facial topography. Three months after a four-treatment course of Emface, the average volume in the upper cheeks increased by 3.3 mL while the lower face saw a volume reduction of 2.3 mL. “This effectively created a ‘lifted’ appearance with a more well-defined jawline and reduction in sagging jowls,” said Dr. Halaas, who was one of the study authors.
Overcoming Resistance
Primary non-response to neurotoxin has been noted in the literature but is considered very rare and may arise from a variety of sources.4 Clinically, concerns about neurotoxin resistance most often refer to secondary non-response, where previously seen outcomes become lessened in quality and/or duration after repeated, regular therapeutic exposure. This likely results from antibody formation over time. Recommendations to prevent or treat resistance include switching to a different toxin or withholding treatment to allow the antibody response to diminish or disappear altogether. “When I see resistance – and I do see it because we do a high volume of neurotoxin – my first question is about where they were treated and what toxin they received,” Dr. Halaas mentioned. “There may be incidence of counterfeit product, which is becoming more common, or weak technique, but if they are not responding, the typical next step is to try a different brand among the big five available in the U.S. and/or taking a break from injectable neurotoxin for a while. Some toxins may be less antigenic or may just be different enough to overcome resistance.”
According to Dr. Holden, Emface could provide a solution for patients who experience neurotoxin resistance. “You simply substitute the device for neuromodulator treatment and wait several months before resuming injections, periodically. This also provides a better result overall.”
Emface can also be used in conjunction with neurotoxins and potentially deliver superior outcomes. “We usually do the neurotoxin first, then a course of four sessions of Emface,” Dr. Halaas explained. “We may recommend an extra session or two for older patients. The technique is very straightforward.”
A pilot study combining Emface and neurotoxin was presented at the Maui Derm 2023 Annual Meeting (January 23 - 27, 2023, Maui, Hawaii)5 by Suneel Chilukuri, MD. Results showed that the use of neurotoxin before Emface did not inhibit facial contractions necessary for the HIFES treatment to work properly.
The cohort included 12 patients. Two patients were toxin-only control, and the ten remaining received a course of four sessions with Emface starting one to four weeks after neurotoxin injection. No adverse events were reported. Assessment of digital photography, facial expressions, patient comfort and patient satisfaction at one- and three-month followups revealed high efficacy and satisfaction. 
According to the study, all Emface patients reached satisfactory contractions during sessions; 92% reported high satisfaction with treatment comfort and outcomes. More than 90% of patients experienced aesthetic improvement with facial expressions known to be hampered by neurotoxin treatment (smiling, frowning, expression of surprise). Dr. Chilukuri elaborated on this concept significantly in a review article later in 2023.2
Strategic Synergy
There is always demand for a more comprehensive approach to facial aesthetic treatments, according to J.D. McCoy, NMD, medical director of Contour Medical (Gilbert, Ariz). Emface is a revolutionary modality in that respect. “This represents an evolution of what we can do with neurotoxin,” he said. “You may use neurotoxin differently and more artistically when incorporating Emface, and if you space out the treatments you can effectively deal with neurotoxin resistance. Thus, Emface can be used as a complementary treatment with neurotoxins with a great potential benefit.
Most people do not like needles to the face but tolerate them when they like the results. Also, people describe their face as being ‘lighter and tighter’ after Emface, and they are eager to do maintenance even before the result begins to diminish. Treatment affects more layers of tissue than neurotoxin so there is a potential synergy, and with Emface there is no downtime.”
According to Dr. McCoy, using neurotoxin to target depressor muscles and Emface to target the elevator muscles in the forehead results in less opposing force, balancing the brow. “It creates a beautiful balance of relaxing and decreasing the ‘pulldown’ while improving the tone of what is pulling everything up. It is almost like a tug of war where you are intentionally putting the weaker individuals on the same end. In the mid-face, Emface targets the zygomaticus major and minor and the risorus. By injecting neurotoxin to affect the lower face depressors, specifically the depressor anguli oris (DAO), the platysma and the mentalis, a finger breadth above the mandible and potentially in the platysma, you are relaxing the key muscles pulling down against the muscles Emface is pulling up. The challenge is that treatment of the lower face with neurotoxins has always been considered more technically difficult, and it requires detailed understanding of anatomy.”
A Practice Differentiator
From a business standpoint, providing a solution to toxin resistance is a significant opportunity for those wanting to differentiate themselves from the competition. Sam Patel, MD, founder of LIV Wellness Lounge medspas (Ottawa and LaSalle, Ill.) and Astra Culture, is a medspa consultant who drives and shares business innovation in the field. “In any typical aesthetic practice, injectables may represent 
upwards of 50% or even 60% of revenue and contribute greatly to reliable cash flow,” he explained. “Their accessibility also serves to bring people into your practice and expose them to your wider armamentarium, much like the inexpensive hamburger brought people into McDonalds who then purchased other things in addition, building a universally known business empire. Similarly, the low barrier to entry and relatively low cost of injectables allows patients to have that consistent and priceless positive, trust-building experience with their aesthetic practitioner.”
Dr. Patel added that beyond efficacy and safety the main reason to address neurotoxin resistance using Emface is because toxin resistance is news people will take note of. “Resistance is not new or unknown, but it is more widely discussed. We will see continued discussion as more and more patients experience it and share it on social media. Propagation by social media has a cascading effect.” The practice that offers Emface will be poised to offer a real solution that delivers safe, effective and reliable results.
“Emface does two things here,” Dr. Patel continued. “First, it provides a viable treatment option to those who do not want the needle. Secondly, both modalities may be used together to enhance the outcomes, or separately to space out and minimize the potential to develop resistance. Younger and younger patients are seeking preventative neurotoxin, making this even more important.”
Not only is Emface easy to use, but it also does not require the skill of a well-trained and experienced injector, making it cost effective. “Success with neurotoxins has a dependency – the injector – who can make or b
reak your business. Bear in mind that patients want convenience and comfort as well as ‘natural’ results, which has been the trend driving innovation in all areas of aesthetic medicine for decades. This global cultural shift toward convenience and ‘natural’ works in favor of Emface. People do not necessarily want to come in and get injected four or five times a year and are increasingly shying away from introduction of foreign substances into their bodies, but the natural result Emface provides – restoring facial topography from the muscles upward to the skin – is very appealing. So you can use them separately or together, appealing to a wider range of patients.”
Emface can also be used to treat the neck using its new submental applicator, Emface Submentum, which is specifically designed for this area. “Emface forehead and cheek applicators are designed to treat skin superficially, along with underlying tissues and muscles, to redistribute fat and restore youthful facial contours. Emface Submentum targets soft submental tissues as well as the digastric muscle to reduce submental volume and improve skin laxity,” Dr. Holden explained. It primarily 
affects the digastric muscle and nearby muscle structures, retracting tissue and reducing double chin. Jawline definition is also improved. “The results are game-changing. Everyone knows that treatment of the double chin helps the facial result by providing a consistent global improvement without obvious demarcation between face and neck. Injection lipolysis is effective, but people do not tolerate it well, plus you swell up like a bullfrog each time, temporarily. With Emface Submentum you get no downtime and significant volume reduction, with improvement of overlying skin as well.”
A presentation at the 43rd Annual Conference of the ASLMS (Baltimore, Md.)6 detailed results of the Emface submental applicator used on the neck. Patients (n=37, 42.2 years ± 12.4, skin types II-V) underwent a course of four 20-minute treatments with Emface submentum and cheek applicators. Analysis of both 3D imaging and magnetic resonance imaging (MRI) showed reductions in double chin volume of 10.77 mL and 36%, respectively. The majority (94%) of patients reported high satisfaction.
“What this all represents to me,” commented Dr. Patel, “is the continuing commitment to science and development that we see with BTL Aesthetics. They are not resting on their laurels and are unafraid to share the spotlight with other therapies, which is very wise when you consider that the best outcomes are seen when multiple treatment vectors are employed together. There is definitely more to come, and it will benefit both patients and practitioners.”
References:
1. Ho WWS, Albrecht P, Calderon PE, et al. Emerging trends in botulinum neurotoxin A resistance: an international multidisciplinary review and consensus. Plast Reconstr Surg Glob Open. 2022 Jun;10(6):e4407.
2. Chilukuri S. Holistic approach for noninvasive facial rejuvenation by simultaneous use of high intensity focused electrical stimulation and synchronized radiofrequency: a review of treatment effects underlined by understanding of facial anatomy. Facial Plast Surg Clin North Am. 2023 Nov;31(4):547-555.
3. Halaas Y, Boyd CM, Gentile R, Chilikuri S, Clark-Loeser L. Novel HIFES and RF technology for comprehensive facial enhancement and volume improvement in patients. Data on file, BTL Aesthetics.
4. Bellows S, Jankovic J. Immunogenicity associated with botulinum toxin treatment. Toxins (Basel). 2019 Aug 26;11(9):491.
5. Chilukuri S. Non-Invasive facial sculpting with novel technology: utilizing HIFES muscle stimulation and RF heating in patients following neuromodulator treatment. Presented at the Maui Derm 2023 Annual Meeting, January 23-27, 2023, Maui, Hawaii.
6. Jacob CI, Clark-Loeser L, DiBernardo B. Efficacy of synchronized RF+ and HIFES muscle stimulation in enhancing the appearance of the submental region. Presented at the ASLMS 43rd Annual Conference, April 11-14, 2024, Baltimore, Md.
