It’s one thing to have an arsenal of effective devices and technologies in one’s aesthetic practice, it’s quite another to have the insight, experience, knowledge and skills to optimally use those technologies. We asked four aesthetic experts to share the unique experiences and inventive techniques that have empowered them to achieve unparalleled outcomes in some of the most popular treatments.
Perfecting the nonsurgical facelift
Michael T. Somenek, MD, a facial plastic surgeon in Washington, DC, shared his SomenekMD Signature Lift technique, which is a nonsurgical facelift using a trifecta of radiofrequency (RF) and other technologies.
“I start with the FaceTite device from Inmode (Lake Forest, Calif.), a bipolar radiofrequency (RF) handpiece that I use for the lower face and neck to target skin tightening,” Dr. Somenek began. “The probe goes underneath the skin and heats up the tissues to a certain temperature. The fibrous attachments contract, which really tightens the overlying soft tissue envelope. Over time we see gradual, yet progressive tightening to the treated areas.”
To provide a more comprehensive result, Dr. Somenek adds two levels of treatment that target skin texture and healing.
“I added microneedling with RF. There are several devices that I use to accomplish this. I’ve used the Fractora device (Inmode) and most recently the Morpheus8 (Inmode),” he said.
While standard microneedling causes controlled damage to the skin with microneedles, Dr. Somenek believes adding RF to microneedling elevates the amount of improvement possible with microneedling only.
“So, I follow the FaceTite device with microneedling, where I create microchannels on the skin’s surface while simultaneously heating the tissues,” he said. “For the third part – in an effort to expedite healing and stimulate collagen – I apply platelet-rich plasma to the surface of the skin. If I have any left over, I inject it under the skin.”
PRP is rich in growth factors that can stimulate receptors of the cell membrane and stimulate collagen. So, it made complete sense to Dr. Somenek that applying PRP when the microchannels were still open would allow the skin to capture the growth factors, thus encouraging collagen stimulation and speeding the healing process.
According to Dr. Somenek, studies have validated that PRP speeds up healing and reduces post-treatment redness.
My Signature Facelift approach appeals to patients because it doesn’t require incisions or downtime, he said.
Ideal candidates are patients who are not quite ready for a surgical facelift procedure but are looking for some improvements to the jawline and the neck. “That can be someone in their early 40s, who has very mild skin laxity,” according to Dr. Somenek.
In addition, patients who have had the surgical facelift and don’t want another, yet they are seeing tell-tale signs of aging return and want to address them, also make good candidates.
“I frequently tell people that the Signature Lift can provide somewhere around 40% of what surgery can provide. If that resonates with them and meets their expectations, that really makes them an ideal candidate for the procedure,” Dr. Somenek said.
“The great thing about this sort of combination treatment that I’ve developed is that it is suitable for all skin types. You are not putting anybody at risk, such as darker skin types for hyperpigmentation,” Dr. Somenek noted. “The reason being is the only part of this procedure that you would have to worry about is the microneedling with radiofrequency, and for darker skin types I use coated microneedling tips. Only the very end of the tip emits energy, so you are not emitting energy at the very surface of the skin that would cause destruction of that skin.”
Determining ideal settings has been an evolution for Dr. Somenek, who has performed more than 180 SomenekMD Signature Facelifts.
“It really depends on what the skin type is, how thick the skin is and how much laxity you are treating. You can’t necessarily say the same temperature works for everyone. It certainly comes with experience,” he said.
An eye for neurotoxins
Oculoplastic surgeon José Raúl Montes, MD, believes injecting neurotoxins is the most precise and predictable procedure in cosmetic surgery today.
“Regrettably, I believe the use of Botox [Allergan] and other neuromodulators is either overestimated or underestimated by practitioners and there is a complete misunderstanding from the patient perspective that the procedure is entirely dependent on the hands that inject,” said Dr. Montes, a speaker, trainer and key opinion leader for Allergan, who practices in San Juan, Puerto Rico. “I do a lot of injection demonstrations around the world and I see many practitioners doing Botox and missing the nuances that will give the best result.”
Cosmetic providers can achieve predictable results with neuromodulators like Botox, that give patients a wow effect. But there are rules, Dr. Montes pointed out.
One common misconception among providers is that neuromodulators are “wrinkle erasers.” Rather, Dr. Montes uses Botox in a very different way – to improve the facial dynamics. He asks how he can use the product to enhance patients’ expressions instead of limiting people’s them.
Injectors should have a keen knowledge of where a patient’s eyebrows should be based on gender and age, for example. Then they should ask themselves how to give the patient’s face more equilibrium and correct asymmetries, by injecting not only the upper face, but also the lower face.
Injecting the whole face and neck leads to more natural looking improvements, according to Dr. Montes.
And the fourth rule: The ideal neurotoxin treatment is usually coupled with dermal fillers. According to Dr. Montes, fillers and neurotoxin are like the Frank Sinatra song, Love and Marriage. ‘They go together like a horse and carriage.’
There are rules for optimal results from this combination approach, as well. Providers shouldn’t overfill cheeks, lips or around the eyes. Rather they should treat patients in a very practical, artistic way – giving a fresh look, without looking injected.
Tips for beautiful lips
Women, who are the typical patients that request lip rejuvenation, generally share the same or similar concerns, Dr. Montes expressed. Either their lips are losing volume or don’t have the volume they want. And many detest the small radial perioral lines around their lips.
“In the young woman, the idea is to enhance the lips by giving them a little more projection,” Dr. Montes said. “On the contrary, when the patient gets a little older the idea is to revolumize, meaning that you have to replace the volume that has been lost.”
Either way, Dr. Montes almost always uses a cannula to treat the lips. “This allows me to deposit the material with less bruising and edema,” he said.
“I place the cannula in the center of the lip and avoid the borders. By giving volume in the center of the lips, in that junction between the moist and dry mucosa, we give the lips a little more projection and volume and avoid marking the border of the lips, which is what makes them look injected.”
Providers should also choose the right products to inject into the lips, and there are good fillers for specifically that area of the face. The best fillers for the job are soft products with low concentration of hyaluronic acid (HA), according to Dr. Montes. As a result of using the low HA products, lips look better, but they still have the dynamics or motion of a non-injected lip, he said.
Threads and sculptra
Threads, used in conjunction with fillers, are making a comeback for face and neck rejuvenation, said Shino Bay Aguilera, DO, a dermatologist who practices in Fort Lauderdale, Fla.
Dr. Aguilera predicts that thread use will only grow, as aesthetic providers better understand how to incorporate newer thread technologies into practice.
“I was very resistant to threads,” Dr. Aguilera admits. “But today’s threads have become increasingly versatile as new products enter into the market offering different lengths, materials and construction of the thread cones and anchoring mechanisms. We are increasingly refining our own techniques as many different threads can be used simultaneously in the same procedure for heavy lifting to fine skin conditioning.”
Today’s threads are made from material like injectable poly-L-lactic acid and absorbable suture material like polydioxanone, so these threads will also condition the skin with collagen, he noted.
When talking with his patients, Dr. Aguilera uses the analogy that the deeper facial tissues, including bone and fat, are shrinking and disappearing.
“It is like you had a really nice suit tailored for you and all of a sudden you lose a massive amount of weight. You can try and build up the tissues with fillers or simply bring your suit to the tailor and take it in,” he said.
Dr. Aguilera said he can slow down the changes of the deeper tissues by injecting Sculptra Aesthetic (injectable poly-L-lactic acid) from Galderma. With Sculptra, Dr. Aguilera addresses skin laxity and can imitate and maintain the deeper tissues including the architecture of the periosteum which is the most important tissue.
“When that goes away, you can forget it. You can pull all you want and not get the best results,” he said. But it is hard to imitate the deeper tissues with just a gel, Dr. Aguilera admitted.
“It doesn’t look quite right after a while. So, I saw a need for something else,” Dr. Aguilera explained. “When you use threads, you pull the skin tighter so that takes away the necessity to use a lot of fillers for the sake of lifting. If you want lifting – pure lifting –it is better to use threads and pull the skin tighter.”
“Once patients understand the concept of how threads reposition tissue differently for lifting without excessive volume, they have been eager to adopt this new approach. We use them alone or with fillers depending on desired results,” Dr. Aguilera shared.
Nonsurgical therapies to enhance surgical results
Jennifer Levine, MD, a facial plastic surgeon in Manhattan, N.Y., does a lot of rhinoplasties and has learned that it often takes more than the surgery alone to achieve optimal results.
“Patients might also need submental liposuction, cheek or lip filler and maybe buccal fat removal to get their face to be more sculpted. They may need chin filler or a chin implant. A lot of it is about balancing the face,” she said.
Dr. Levine will usually do the surgical rhinoplasty first, adding other treatments immediately after surgery. She tries to combine treatments at the time of surgery to minimize pain and swelling during recovery.
She takes the same approach when doing blepharoplasty, with special attention on the lower lid.
“Often if you are removing fat there also has to be some adjustment to the cheek. And it can’t all be addressed just with the surgical blepharoplasty because that patient might also need fat grafting. If they don’t want to do fat grafting, we can use an injectable filler to give the cheeks more volume,” Dr. Levine said.
Winning body treatment combos
Dr. Levine also performs non-invasive body contouring and said combination approaches with today’s technologies often yield the best results.
“We do a lot of either EMSCULPT from BTL with Sculptra, which lifts the butt, helps to give it a little more contour and helps the skin quality and texture,” she said.
In Dr. Levine’s opinion, this combination is really best for a smaller patient who has a smaller butt overall because you can get the result you want with a more reasonable amount of product,” she said.
Other body contouring combinations that are among Dr. Levine’s patient favorites is combining Sculpsure, to remove the fat of the banana roll, with Sculptra to lift the buttocks. “This also gives the butt more definition,” she said.
She also uses Ultherapy with Radiesse (both from Merz Aesthetics) to treat the backs of the thighs. A lot of people look like they have cellulite on the backs of their thighs when it is really skin laxity that is causing the uneven skin surface, Dr. Levine explained.
“The combination of Ultherapy and a biostimulatory filler used in a more dilute form like Radiesse (we’ve used Sculptra, too) gives a really nice result,” she noted. “If you use one of the standard treatments to break the bands, the back of the thigh might end up looking more lax.”
Ultherapy will help the body to produce its own collagen and elastin, and a dilute biostimulatory filler helps with skin quality and texture.
The combinations of Ultherapy and Radiesse or Ultherapy and Sculptra also are good options for treating skin laxity around the knees, Dr. Levine added.
Regardless of what combination you choose, Dr. Levine says it is important that patients have realistic expectations and that providers choose the right candidates for non-invasive body contouring treatments – even when they are using combination approaches.