Besting Needle Fatigue: Are Energy-Based Treatments the Answer?Besting Needle Fatigue: Are Energy-Based Treatments the Answer?

In medicine, needle fatigue is defined as a waning commitment to continue with prescribed injectable treatment primarily resulting from poor tolerability. Not to be confused with filler fatigue – the negative result of getting too many dermal filler injections over time – needle fatigue happens in aesthetics too. It is attributed to the discomfort or irritation caused by repeated injections, from neurotoxin, threads and other needle-based aesthetic treatments. Whether it is an aversion to needles or unnatural-looking results, experts agree: there are solutions.

Unnatural = Unhappy

According to a 2024 survey conducted by the American Academy of Facial and Plastic Reconstructive Surgery (AAFPRS), when considering a procedure, 24% of respondents reported their patients’ biggest fear is looking unnatural. “More than a few” unhappy patients have sought solutions with dermatologist Jacqueline Watchmaker, MD, of Southwest Skin Specialists in Scottsdale, Ariz., because of dissatisfaction with injectable results. “I have especially in the past year seen a shift in patient preference toward more of a multi-modality approach to aging and think social media has helped with that,” she shared.

Suzanne Kilmer, MD, founder of the Laser & Skin Surgery Center of Northern California in Sacramento, Calif. uses combination approaches, patient selection and technique to preserve natural-looking faces.

Vivian Bucay, MD, founder of the Bucay Center for Dermatology and Aesthetics in San Antonio, Texas, believes social media plays a role by perpetuating the concerns about looking overdone, even when patients are not. When Dr. Bucay’s long-time patients express fearfulness about what fillers might be doing to their faces, Dr. Bucay pulls out their past photos. “I show them a picture of themselves many years ago and today (I do this all the time), and they see that they look exactly the same,” Dr. Bucay explained. “I tell them my job is not to change the way you look; it is to restore what is missing or to keep you in a hovering pattern. That is why we choose certain treatments based on what those goals are. We customize.”

Combine and Customize

These experienced aesthetic physicians say it is not the fillers that are causing the fatigue or fear. Rather, it is the way they are used and overused. All three – Drs. Bucay, Kilmer and Watchmaker – use injectables regularly in practice, but often in combination with energy-based devices, skincare and laser procedures.

Relying less on injectables alone and more on combination approaches is what works for Dr. Watchmaker. Her go-to devices for anti-aging combinations include the nonablative fractional lasers, such as the Clear + Brilliant® (Solta Medical), Fraxel® (Solta Medical), LaseMD (Lutronic) or MOXI™ (Sciton). “These never make people look weird or abnormal. They help skin quality, pigmentation and can help with fine lines,” Dr. Watchmaker stated. She also uses more aggressive lasers – ablative CO₂ and Erbium – for significant help to fine lines around the mouth and eyes. Despite the increased downtime associated with ablative lasers, results keep many patients from needing more and more filler.

According to Dr. Kilmer, other procedures can help fillers last longer. Fraxel, for example, smooths skin and evens out color and texture. “If there is crinkling and a little bit of laxity on the superficial part of the skin, Fraxel is a great way to treat that. Then maybe patients do not need filler as much,” Dr. Kilmer explained. “Fraxel Dual was recently shown to decrease risk of skin cancer by 50%, so it makes skin healthier, too.”

Sofwave™ (Sofwave) tightens the skin’s deeper layer, eliminating some of the need for filler. And Emface® from BTL Aesthetics (Marlborough, Mass.) is great for natural lifting of the brows and cheeks and helps with the submental region, noted Dr. Kilmer.

Some fillers also offer longer lasting and more natural results for some areas of the face. Injectable poly-L-lactic acid (PLLA), for example, is ideal for the mid cheek and requires less product than if one were to use hyaluronic acid (HA) fillers.

Dr. Kilmer recommends that injectors are careful not to overfill with HA fillers. “For example, I might use 100 units of Botox® (Allergan Aesthetics, an Abbvie Company), and a syringe of filler in many of my patients every three to four months. I am taking that one syringe of filler and spreading it out,” she noted.

Injectable Alternatives

Success in overcoming needle fatigue is identifying the problem and using the right monotherapy or combination to address it.

Although aesthetic providers might be inclined to reach for dermal fillers to treat lines around the mouth, these patients often are concerned more with texture than volume, according to Dr. Bucay. So, she recommends the Exion™ from BTL Aesthetics, which combines radiofrequency (RF) with ultrasound.

“BTL Aesthetics has shown treatment can increase the amount of HA in the skin after a series of four treatments,” Dr. Bucay explained. “That, of course, is going to make skin look a little more hydrated and plumped up, but not necessarily volumized because it is not injected.”

Dr. Bucay pointed to devices like Emface, which combines muscle stimulation and RF. “In the cheeks, [Emface] targets the zygomaticus major, so you can create the look of a more sculpted cheek. It requires a series of four, maybe up to six treatments, weekly. Then you have to do maintenance every few months,” she commented. While Emface can create a more lifted look because of tightened muscles, it will not replace volume lost in the fat pads. That requires a combination treatment with fillers. Dr. Bucay is less likely to use fillers, nowadays, to treat under-eye hollows, she shared. Instead, she uses a topical collagen biostimulatory agent – PRX Derm Perfexion (WIQO). “It is a combination of trichloroacetic acid with hydrogen peroxide. We use it a lot for tightening skin around the eyes and get really nice results,” she emphasized.

Dr. Bucay noted that while revenue from HA fillers is down at her practice, in other areas, such as biostimulatory or regenerative medicine, revenue is up. “Microneedling with RF is having its moment right now. It is everywhere. People are also using fractional laser to deliver actives into the skin,” Dr. Bucay stated. “It is not instant gratification. It is a more gradual response but tends to look more natural.”

Comfort is Key

Walter Tom, MD, founder Dr. Tom Cosmetic Surgery in Santa Rosa and Napa, Calif. and Maui, Hawaii, shared that he has not encountered patient concerns about needle fatigue. “In fact, due to the growing demand of biostimulators, I am injecting more acellular adipose tissue matrix, PLLA, platelet-rich fibrin, and now hyperdilute Radiesse® (calcium hydroxyapatite) from Merz Aesthetics (Raleigh, N.C.),” he commented.

According to Dr. Tom, making injection sessions more comfortable has helped prevent needle fatigue in his practice. To do so, he uses ice, frequent needle changes, tractioncountertraction, patient education, local anesthesia (where appropriate) and ProNox™ (CAREstream America).

Down But Not Out

Topicals and energy-based devices might be increasing their roles in anti-aging regimens because of aesthetic needle fatigue but experts agree that they are not replacing the need for fillers. “There is no way you are going to get the same kind of lifting [without filler] if someone is really volume depleted,” Dr. Bucay noted. “Filler cannot fix everything, but it does have its place.” It is rare that Dr. Watchmaker will talk only about injectables during a patient consult for anti-aging treatments. “If you just address volume loss or just address the wrinkles on the forehead, you are missing out on facial skin, which contributes so much to aging,” Dr. Watchmaker stated.

Dr. Watchmaker, who moderated a session on combination treatments with injectables and energy-based devices at the 2024 annual meeting of the American Society for Laser Medicine and Surgery (ASLMS), said women in their 50s often are concerned with volume loss of the mid and lower face. “On average, I use only one to two syringes of filler to build up some of the lost volume per session. I like to gradually build volume rather than use four to six syringes in one visit. I also like to use a little bit of a neuromodulator, like Botox, around the mouth – especially around the chin to help prevent that orange peel texture. Sometimes I use it in the upper cutaneous lips to help prevent the constant contraction that forms an etched-in line above the lip,” Dr. Watchmaker remarked.

Then, to resurface the lines and wrinkles that have accumulated, especially if patients can tolerate some downtime, Dr. Watchmaker recommends using the CO₂ or erbium laser to stimulate collagen and smooth out and reduce lines around the mouth. “I do think a combination of a little Botox, a little laser and a little filler gives a beautiful and natural result,” she concluded.

Product Watchlist

Sinclair North America (New York, N.Y.) has built a portfolio of differentiated, complementary aesthetic technologies that target unmet clinical needs for effective, high-quality, longer-lasting, natural-looking and minimally invasive treatments. Sinclair’s portfolio includes the V-SERIES, Préime® DermaFacial, EnerJet and Primelase – which deliver advanced, non-invasive energybased treatments aimed at rejuvenating skin and improving overall aesthetic outcomes. From the versatile skin resurfacing and tightening of the V-SERIES to the multi-technology approach of Préime DermaFacial for hydration and radiance, these devices offer a comprehensive solution for skin health. Precision targeting with EnerJet promotes deep dermal remodeling, while Primelase provides fast, effective hair removal for all skin types. These technologies seamlessly integrate into clinic protocols, providing visible, long-lasting results with minimal downtime.

NOUVADerm™ from Aesthetic Management Partners (Cordova, Tenn.) is an advanced skin resurfacing platform, with fourth-generation laser resurfacing. The NOUVADerm 1927 nm Thulium Fractional Laser offers a unique and versatile approach to aesthetic treatments, targeting multiple areas, including the face. NOUVADerm provides options for non-ablative, sub-ablative and ablative treatments that ensure customizable results based on individual needs. What differentiates NOUVADerm is its power at 120 watts, providing energy delivery form 10-, 20- and 30-mm spots sizes with continuous energy delivery. This allows the practitioner to treat a face in six minutes and to address pigmentation and crepey skin and wrinkles. The NOUVADerm device allows a selection of parameters and addresses a wide range of skin concerns – from unwanted pigmentation to fine lines and wrinkles, acne scars and uneven skin tone and texture – with precision and efficiency.

ADVATx from ADVALight (Escondido, Calif.) delivers non-invasive, energy-based treatments that refresh and refine for healthier, renewed skin. Equipped with dual 589 nm and 1319 nm wavelengths, the device effectively targets 25 FDA/CE-cleared indications for skin types I-V, promoting visible improvements in tone, texture and overall quality. Integrating seamlessly into practice protocols, this device opens pathways to optimized treatment benefits, encouraging long-lasting results and radiant skin – all without social downtime.

The SmartXide PRO from Monarch Aesthetic Services (Laguna Hills, Calif.) is the latest in CO₂ laser technology that allows for both aggressive, fully ablative CO₂ treatment and minimally invasive resurfacing treatment, known as SMARTlase treatment. Utilizing the SmartXide DOT technology from DEKA Lasers, SmartXide PRO has an exclusive SmartPulse technology and SMARTSTACK function to achieve superior efficacy and safety levels during treatments. Practices can benefit from this versatile device that allows them to tailor treatments to their patients and provide optimal needle-free results.

OptimasMAX from InMode (Irvine, Calif.) is a multi-functional platform, featuring nine advanced energy-based technologies for enhanced control, impressive power and faster treatments. OptimasMAX comes with Morpheus8 and Morpheus8 Deep fractional radiofrequency (FRF) microneedling, Lumecca Peak advanced IPL, Forma and Plus bipolar thermal skin treatments, VasculazeMAX vascular resolution technology, and three laser hair removal handpieces. Combining energy-based treatments like Morpheus8, Lumecca Peak IPL and Forma or Plus enables practices to customize procedures to deliver tailored, transformative, natural-looking results. Lumecca Peak, engineered with 25% more optical power and a high pulse repetition rate, reduces treatment times to produce faster results in fewer treatments. Morpheus8 and Morpheus8 Deep are FDA cleared for soft tissue contraction. Equipped with Scale and Burst modalities, these versatile devices automatically deploy bipolar RF to multi-level treatment depths and programmable energy levels in millisecond intervals with a single pulse, delivering safe and efficacious procedures.