As the latest statistics published by the American Society of Plastic Surgery show in 2010, the fastest growing procedures in cosmetic surgery are not surgery at all. Rather it is such non-invasive procedures as Botox, injectable fillers and focused and high-intensity light face and body treatments. This is a trend that has been ongoing now for the past decade and shows no sign of slowing down anytime soon. Recent studies also show that up to 25% of people would have some form of cosmetic surgery if cost and recovery were not an issue.

Whether it is to avoid the costs and recovery of more expensive surgery or to treat cosmetic problems for which there is no good surgical solution, non-surgical treatments continue to expand. One such area of expansion is the use of light-based and energy therapies. From skin tightening, fat reduction or the the improvement of cellulite, treatment options appear as often as new devices become clinically available. While light-based treatments were once thought of as just laser devices, used largely for skin resurfacing and hair reduction, this is no longer the case. Energy-based devices are now available that uses infrared light, ultrasound, and radiofrequency waves, technologies that long have had FDA-approved uses in diagnostic and therapeutic traditional medicine.

One such recent device is that of Exilis. This is a monopolar radiofrequency device that has recently received FDA clearance for localized fat reduction and skin tightening. With penetration depths that past the skin level by a few centimeters, stubborn fat deposits can be treated even over large areas. The radiofrequency waves disrupt the membranes of the fat cells by the generation of heat causing them to spill their lipid contents. As the liquid fat is absorbed over time, the size of the fat deposit becomes less. Exilis treatments are done in the office as walk in and walk out therapies requiring no downtime or recovery. It takes a series of 4 to 6 treatments spaced a week apart to see the best results.

The radiofrequency of Exilis also has a skin tightening effect. By heating the underside of the skin (deep dermis) through the radiofrequency energy, collagen is produced which causes the skin to tighten. This is particularly effective in the face, the jowls and neck, where the skin and underlying tissues are thinner. Because lower energy levels are used, it feels very much like getting a hot stone massage. Since the production of collagen is more gradual, treatments need only to be done every two weeks for two to three months. Some may call this a RF (RadioFrequency) Facelift as it can tighten the face without surgery.

Another energy device example is that of Sciton’s SkinTyte device. As part of their multimodality laser platform, Skin Tyte is high intensity pulsed light known as BBL. (broad band light) By stacking pulses of light over a treatment area, the underside of the skin is heated. This also produces collagen and a skin tightening effect very similar to that of Exilis. Unlike Exilis, however, its energy does not penetrate deep and no fat reduction effect is achieved. As the name implies, it is a non-surgical method of skin tightening.

While Exilis can do fat reduction and Skin Tyte can not, this begs the question as to whether Exilis or SkinTyte is better for skin tightening. It s unknown at this time as to how these technologies compare for their effectiveness. Since my practice has both technologies, I will be able to answer this question better in the future as greater numbers of patients are treated.

Dr. Barry Eppley

Indianapolis, Indiana   

One of the more common things I hear patients say is ‘ I don’t want a facelift….can’t you just tighten a little bit of this saggy skin along my jowl line and neck?’ It is undoubtably a question asked to plastic surgeons around the world. Such a question has led to the development of non-invasive skin tightening devices. Their appeal remains great but their results to date have often been disappointing.

The concept is one of driving energy down to the underside of the skin, heating it up and causing it to contract and tighten. Whether the energy comes from pulsed light, ultrasound, radiofrequency, or lasers, multiple devices are currently available. Beginning less than 10 years ago, early non-invasive skin tightening was associated with significant pain and inconsistent outcomes. As these technologies have evolved, less discomfort with the treatments and more consistent results are being reported.

One critical question about non-invasive skin tightening is how it compares to that of the surgical approach, a facelift. While no one expects a non-invasive approach to be remotely similar to that achieved by surgery, from a cost and value standpoint it has merit to see what those differences may be. Such a study was published in the April 2010 issue of Archives of Dermatology. In this study, patients treated with tadiofrequency (FRF) were compared to patients who received a facelift. Photographs of 15 patients treated with FRF and 6 facelifts patients were evaluated. They reported that the non-invasive approach resulted in 37% improvement of skin laxity compared to that of a facelift.

The most believeable study results in comparing these two treatments would come if the patients had each side of their face treated by the two methods. But this is obviously impractical and will never be done. We are therefore left with the knowledge that non-invasive devices produce some effect but could one expect as much as a 1/3 result of that of a facelift?

While several devices are currently available, it is not known whether any of them works better than another. This comparative study used radiofrequency, whether better or worse results would be seen with other type energy-driven devices is a debate currently left to the manufacturers. But the one thing known for certain is that patient selection is more important than the type of energy used. Older patients with significant skin sagging and wrinkles could expect far less results than a 1/3 of a facelift, and probably closer to minimal observable improvement. Patients in their 30s or 40s with a little bit of jowling and a few wrinkles are much more appropriate candidates. But age aside, the most important determination is the elasticity of the skin and the amount of its looseness. If the skin is in better condition than one’s age would expect, modest results may still be seen.

Multiple non-invasive skin tightening devices exist using different energies including Thermage, Syneron, Cutera and Sciton who are the most visible currently. I currently use the Sciton (SkinTyte) in my Indianapolis plastic surgery practice and have a fair amount of experience with it for jowl and neck treatments. When a patient opts for a SkinTyte series, it is done on the basis that they know it is not a substitute for a facelift… even a more limited jowl lift. They have been educated that it is not a matter of whether one needs surgical skin tightening but whether they want to slow down the aging process and delay the time when one day they will need one.

Dr. Barry Eppley

Indianapolis, Indiana  

There are a lot of patients who are halfway between injectable fillers and a traditional facelift. Their facial contouring concerns are not really adequately addressed with short-acting fillers but they are not yet prepared to go as far as a surgical facelift. Most of these patients are between the ages of 40 to 50 and may already be using or at least have tried Botox and injectable fillers. As they have continued to get older, they have found that new aging problems have developed around the jawline, the neck and the lower face.

The lower part of the face is out of reach for what any injection methods can really improve. Helping to bridge the gap before a facelift is considered is a facial procedure that I call in my Indianapolis plastic surgery practice ‘Smart and Tyte’. To help remove neck and jowl fat and tighten skin, the combination of Smartlipo and Skin Tyte is done. This is a two-pronged approach using laser liposuction for the neck and jowls followed weeks later by a series of SkinTyte office treatments.

For the neck and jowl fat, a laser probe is inserted from a few millimeter incision under the chin. The fat is treated at a depth of immediately subdermal to just above the platysma muscle is a fanning fashion out from under the chin. The entire procedure takes about 30 to 45 minutes and is done under local anesthesia. Downtime is not really an issue as there is only the mildest of discomfort afterwards. Swelling and bruising, however, will take a week or more to completely resolve.

Beginning three weeks after surgery, in-office pulsed light treatments (Skin Tyte) are done to aid the skin tightening process. Between the intial heat of the laser and these treatments, good skin contraction can be obtained. The Skin Tyte process is done every two weeks for a series of four total treatments. I judge the final outcome of this combination approach at six weeks after completion of the final in-office treatment.

For patients with the beginning signs of jowling and neck changes with faborable skin tone, really good contouring of the fat and tightening of the skin can be obtained. Such results can last for years and can turn back the clock five to seven years. Because the laser treatments isdone under the skin, it can be performed on patients with any type of skin. Skin Tyte is turned down in power and intensity for darker pigmented patients to avoid any risk of pigmentation changes for the external treatments.

The key to a successful ‘Smart and Tyte’ procedure is patient selection. It is not for every patient that wants to avoid a facelift. In fact, most patients that want to avoid a facelift usually are in need of exactly that. While these procedures have a minimal downside, their greatest risk with improper patient selection is lack of any significant change making it a poor economic value.   

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

One of the earliest signs of facial aging is the development of jowls or jowling. The jowls are areas of skin and fat that have fallen from the side of the face to hang along or below the jawline. As we age, these areas tend to become more noticeable as the sag worsens. The once straight jawline of youth is gradually replaced by the saggy full jowls of the aging face. Why this occurs is the age-old phenomenon of time and gravity, weakening the attachments of the skin to the underlying muscle so that a tight bond between the two no longer exists.
I see many patients who are bothered by jowling, including younger patients who often see this as one of the first signs of real aging. There are numerous options to treat the jowls, both surgical and non-surgical, with varying degrees of effectiveness. The most effective methods, to no surprise, are surgical and include facelifts and liposuction. A facelift in its fullest extent is a jowl-neck lift. In its more limited form, it is primarily a jowl lift. It works by pulling skin and deeper tissues up and back, eliminating the jowls by pulling loose tissue above the jawline again. The loose jowl tissue is simply repositioned and not removed. More minor procedures that have recently gained popularity, which aims to do the same thing, are the Threadlifts or Featherlifts. In this simple procedure, barned sutures are passed deep into the cheek and facial tissue above the jowl area and cinched up from above. For very minor degress of jowling, this has some benefit but is not effective enough with large amounts of jowling and the long-term results with these procedures is suspect. Actually removing jowl fat can be done with liposuction, reducing their size. This can be done alone or in conjunction with some form of a facelift. When performed alone, liposuction of the jowls must be done very carefully and conservatively, lest you get irregularities that are apparent in the overlying skin. When done with a facelift, the lifting and tightening of the skin usually eliminates this concern.
Non-surgical options include skin tightening by heat-generating devices and LipoDissolve. Neither approach treats both of the jowl issues, skin and fat, and therefore they are usually less effective than surgery. Heating the underside of the skin through a series of treatments can cause a tightening effect. Devices such as Thermage or SkinTyte do it differently but the objective is the same, heat up and the skin on its underside and cause it to tighten. The long-term results of this procedure appear to be short-lived and that is why I perform them in conjunction with other procedures rather than as a stand alone technique. LipoDissolve treats the jowls by fat-dissolving injections done as a series. As the fat dissolves, the jowl is reduced in size. In my experience, it is just as effective as liposuction, albeit a lot slower. When performing non-surgical jowl reduction, I like the combination of LipoDissolve and Skin Tyte. That combination seems be particularly effective as both components of the problem, skin and fat, are addressed. They are also great touch-up procedures to do after a facelift when a little rebound relaxation in the jowl area occurs.
The jowsl can be treated by numerous surgical and non-surgical methods. Limited and full facelifts produce the best and most long-lasting results and should be the first choice when moderate to severe jowling is present. In more minor jowling, LipoDissolve and Skin Tyte work well if the patient can tolerate a slower speed of noticeable improvement.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Spring is finally here – and this is the time of year when one starts looking in the mirror and seeing dull, dry winter-time skin. I’m often asked which skin care treatments are most effective and how patients can best maintain their surgical results. While the answers aren’t the same for everyone, I can tell you there are three truly effective things that you can do to improve your skin’s condition – and doing these things with the start of each new season can really establish a routine easily.

Microdermabrasion. This is easy; effective – and is affordable to do on a regular basis. Honestly, this is the most consistent method to maintain skin that is in good condition – without muss or fuss.

SkinTyte™ Laser Treatments. I am seeing very good results with these treatments, and they have proven to be even more effective when combined with an exfoliative treatment (such as Microdermabrasion). SkinTyte™ is non-invasive, so it’s also easy to do on the way home from work and does not require any recovery time.

MicroLaser Peels™ These are far and away the fastest way to better skin. MicroLaser Peels™ (also called the ‘Weekend Peel’) are the treatment I most often recommend to my own family as a quarterly ‘maintenance’ treatment. Laser peeling has changed drastically since the days when carbon-dioxide lasers were all that were available to us, and we’re now able to do light to medium to deeper peels in the office that produce only a few days of redness and flaking skin – and can be repeated on a monthly basis- rather than requiring weeks of recovery and the expense of surgery. We can be as aggressive or as conservative with each peel as a patient wants, and can base each peel on your needs at the time and any activities you have planned.

This new season is the ideal time to re-evaluate your skin care routine. The above three treatment options, combined with a good skin care program of topical solutions, can being on the sunshine in your own skin!

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis