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January/February 2018January/February 2018

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Thermi offers a tool for virtually every aesthetic need in any practice.

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THERMITIGHT: PRECISE SUBCUTANEOUS RF FOR OPTIMAL TISSUE TIGHTENING 3

THERMISMOOTH: TARGETING LAXITY ANYWHERE ON THE BODY 6

THERMIVA: AN IMPORTANT DEVELOPMENT FOR FEMALE PELVIC HEALTH 9

THERMIRASE: RF TARGETING FOR ENERVATION AND WRINKLE REDUCTION 12

SILHOUETTE INSTALIFT: THE ABILITY TO NONSURGICALLY REDRAPE FACIAL TISSUE 14

TINA ALSTER, MD, FAAD WASHINGTON INSTITUTE OF DERMATOLOGIC SURGERY, WASHINGTON, DC

JASON BLOOM, MD MAIN LINE CENTER FOR LASER SURGERY, ARDMORE, PA

GREG BUFORD, MD, FACSFOUNDER, BEAUTY BY BUFORD, ENGLEWOOD, CO

SUNEEL CHILUKURI, MD, FAADFOUNDER, REFRESH DERMATOLOGY, HOUSTON, TX

JEFFREY R DELL, MD, FACOG, FACSDIRECTOR, INSTITUTE FOR FEMALE PELVIC MEDICINE, KNOXVILLE, TV

Z PAUL LORENC, MD, FACSPRIVATE PRACTICE, NEW YORK, NY

JANUARY/FEBRUARY 2018 | SUPPLEMENT TO MODERN AESTHETICS® 3

T he use of radio frequency (RF) delivery through the skin to stimulate tissue tightening is not entirely new. Nor, for that matter, is the notion of percutaneous RF delivery via microneedle RF devices. But Ardmore, PA facial plastic surgeon Jason Bloom, MD wasn’t

impressed with the results of older devices. Then he found ThermiTight, which he says, “has a wonderful place in my office and for a particular type of patient.” That patient? The “Tweener.”

“It’s that mid-to-late 40s to the early 50s population,” Dr. Bloom explains. “The nice thing is they can get real results in the office.” About 85 percent of his patients that are in their mid-to-late 50s through their 60s and even early 70s are good candidates for lower face and neck surgery. “They have a significant amount of laxity in their neck and in their jowl areas. And they really want results,” he says.

The “Tweeners,” in contrast, tend to be in their 40s to early 50s. “Maybe they’ve tried some of the topical radio frequency devices or even some of the other nonsurgical noninvasive

treatments for the lower face and jowls, and they’ve been unhappy. They want some results, because they just started to see some of the signs of aging in their lower face and neck, but they’re certainly not ready for a lower face lift or a neck lift,” Dr. Bloom says.

“ThermiTight is a probe that’s delivered underneath the skin under local anesthesia,” explains Z. Paul Lorenc, MD of New York City. “It delivers radiofrequency energy to heat up the collagen in the skin. The great thing about Thermi is that we have this feedback loop of external temperature. We have an infrared camera that looks at the area—whether it’s the knees, the arms or the face—which gives me guidance of how much energy I need to deliver. It’s a very controlled way of delivering energy.” The precise energy delivery avoids superficial skin injury.

Few of his patients are treatment naïve, and are therefore familiar with injectable fillers and neurotoxins, Dr. Bloom notes. They understand the concepts of weakening the mus-cles that cause facial wrinkles and placing volume and shape

THERMITIGHT: PRECISE SUBCUTANEOUS RF FOR OPTIMAL TISSUE TIGHTENING

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Courtesy of Jason Bloom, M

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4 SUPPLEMENT TO MODERN AESTHETICS® | JANUARY/FEBRUARY 2018

to the face or plumping the lips with injectables. “Now, I tell them we can tighten the soft tissues of your neck and jowl,” he explains. “One of the most difficult areas that we’ve ever

had to treat as facial plastic sur-geons is the neck and lower face. Now we have an option that’s non-surgical. There’s no scalpel, no sur-gery, and no stitches. And that has been a huge win in my practice for treating these patients.” Treatment takes about an hour and a half.

Dr. Bloom estimates that ThermiTight allows him to achieve 30 to 40 percent of the improve-ment that he can with a surgical procedure. For many patients, that means being able to delay surgery for a period of years. And in some cases, Dr. Bloom will credit a por-tion of the cost of the Thermi pro-cedure toward a subsequent sur-gery. “When they’re 65 and they’re looking to have a face lift, I want them to come back to me and say, ‘You know what, that ThermiTight that we did when I was 50 was money well spent.’ And now it’s like they have a down payment towards using me as their surgeon, and I want them to come back to

me when they’re thinking about face lift surgery.” Having undergone a ThermiTight procedure

would not preclude a patient from undergoing surgery in the future. Dr. Bloom has performed surgeries on patients who have undergone deoxy-cholic acid injection, crylipolysis, and RF treatment and noted no anatomical changes. “I have not seen a difference. It doesn’t preclude anything.”

ThermiTight can be useful for patients who are not interested in surgery but want a treatment that can be performed in-office. Some patients are simply disinterested in surgery. Nonetheless, they may have laxity in their neck and want a little bit of improvement. “That’s the other group that I treat with the device,” Dr. Bloom says.

Greg Buford, MD, of Englewood, CO, agrees. “Often times, we actually have to do this crazy thing called listening to the patient. I’ve learned over the years that some of my patients are actu-ally very happy with some of the results that I

thought were good, but I wish could have been better,” he says. For patients who may be candidates for surgical inter-vention but don’t want an operation, ThermiTight is a viable

“ONE OF THE MOST DIFFICULT AREAS THAT WE’VE EVER HAD TO TREAT AS FACIAL PLASTIC

SURGEONS IS THE NECK AND LOWER FACE. NOW WE HAVE AN OPTION THAT’S NONSURGICAL. THERE’S NO SCALPEL, NO SURGERY, AND NO STITCHES. AND THAT HAS BEEN A HUGE WIN IN MY PRACTICE FOR TREATING THESE PATIENTS”

–JASON BLOOM, MD

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option, he insists. “We really do have to pay attention to what the patients want because often times they are actually happy with less of a result than we envision from surgery. The critical part of the patient interview of the consult is identifying what that patient really wants and really trying to predict what change that they’re going to be pleased with.”

Patients will see results soon after Thermi treat-ment, but the benefits of treatment increase over time. “My protocol is to see patients back in one week just to make sure they’re doing okay. And then I see them at one month, three months, and six months. And you can see the progression,” Dr. Bloom says. “At three months, they’re just starting to really see the tis-sue contraction. And by five or six months, it’s really amazing. “It takes a while for the fibro-septal network between the muscle and the skin to contract via neo-collagenesis. When I see patients back around three months and they’re looking really good, I say, ‘I cannot wait to see you in six months because it’s going to be even more amazing.’”

As new injectable and energy-delivery devices continue to emerge for the neck area, increased marketing is driving patients into aesthetic prac-tices. “They don’t necessarily know which one will be good for them. But that’s the job of the practi-tioner to explain to them the risks and benefits of each of these procedures,” Dr. Bloom says. Among key considerations is the number of treatments required and the potential benefit of treatment.

ThermiTight is a, “one and done kind of treat-ment,” Dr. Bloom says, which offers two important benefits. “Patients like that. For the most part, they don’t want to come back in for multiple treatments. And so to have something that can address these concerns about their lower face and neck in one

treatment is a huge win.” An additional benefit is persistent result. “I tell patients face and neck surgery lasts about seven to 10 years, based on the surgeon and multiple different fac-tors. I tell them I’ve had ThermiTight in the practice since 2014, and I’ve never had to re-treat a patient. Thermi likely keeps working.” n

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GOOD FOR PATIENTS; GOOD FOR PRACTICESWhen it comes to integrating devices into practices, surgeons and practice managers weigh not only the cost of a system but also the costs of disposables. With ThermiTight, disposable costs are low, Dr. Bloom says, well under $300 per patient. The procedure cost, coupled with a low disposable leads to a high return on investment (ROI) for the doctor/practice.

The low consumable cost instills confidence in the doctor that he or she can assure patient satisfaction. Dr. Bloom has never had a non-responder with Thermi. He doubts it would happen, but if he did ever see a patient who felt they had not improved six months after ThermiTight, he would simply repeat the procedure. Even accounting for the disposable and his time, based on the initial cost of the procedure, Dr. Bloom says he would still be ahead.

Courtesy of Jason Bloom, M

D


Skin laxity is a vexing patient concern. Most patients can point to some area on their body—from their eyes to their ankles—where they are bothered by skin laxity. And to target that laxity, the Thermi platform offers two potential solutions. ThermiTight is a minimally

invasive option, where a small probe is placed under the skin for direct heating of tissue. ThermiSmooth uses transdermal energy delivery for broader applications.

For Englewood, CO plastic surgeon Greg Buford, MD, ThermiSmooth, “fits a nice niche…We’ve been using it both as a standalone and also as an adjuvant procedure to both surgical procedures such as liposuction and tummy tuck, and we’ve also used it in combination with the ThermiTight.” And the applications truly run the gamut from the face to the feet. The platform is FDA approved for cellulite, although Dr. Buford says he thinks of it more broadly as a tightening device.

“The ThermiSmooth procedure for the abdomen is a wonderful application, which can very effectively tighten the skin to a certain extent, depending upon the patient’s tissue quality, their age, the degree of skin laxity. With appropriate patient expectations, overall we have very happy patients for those procedures,” Dr. Buford reports.

“As far as ThermiSmooth, we use it all over the body—on the face, on the arms, on the belly, and on the thighs,” explains New York’s Z. Paul Lorenc, MD. “We have a protocol that’s pretty aggressive as far as the frequency of delivering the treat-ment. Typically my protocol is six treatments every two weeks of ThermiSmooth, whether it’s thighs, belly or the face.”

COMPLEMENTARY TECHNOLOGIESWhile he uses ThermiSmooth or its counterpart Thermi250

as a stand-alone treatment, Dr. Buford believes the device excels when used with other technologies and interventions. For example, he frequently uses a combination to treat laxity in the neck. “We’ll use the ThermiTight to begin with to really try to get that initial tightening and then, from there, we’ll actually add several sessions with Thermi250 to even further tighten skin,” Dr. Buford says.

Dr. Buford uses ThermiSmooth around the mouth and around the eyes, coupled with a variety of procedures. “I’ve had this procedure done myself where we basically use a com-bination of several sessions of ThermiSmooth around the eyes to essentially tighten that loose skin around eyes,” Dr. Buford shares. “We’ll also use direct injection of platelet rich plasma (PRP) to the eye area—both the upper and lower lids—and then we’ll microneedle plus PRP to the entire face.”

“I think that’s where the Thermi application is really heading. It’s very nice as a monotherapy, but I would say that it excels in combination with other therapies, such as microneedling, PRP, surgical procedures, or suture lift. It’s really a great adjuvant procedure, and that’s really where you get a lot of synergy,” Dr. Buford says. “We already understand now that the system works, so people like me and others are now combining it with other products and procedures to create even greater results.”

Unlike ThermiTight, where the surgeon creates small aper-tures using either a 16-gauge or an 18-gauge needle to allow entry of the probe to place the energy directly underneath

THERMISMOOTH: TARGETING LAXITY ANYWHERE ON THE BODY

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Courtesy of Greg Buford, MD


the skin, “with the Thermi250 you use a variety of sized paddles to effectively go through transdermally, down into the tissue. With ThermiTight you’re actually directly plac-ing it where you want that heat energy and it’s radiating up. Here, you’re effectively placing it on the skin and it’s radiating down,” Dr. Buford explains.

ThermiSmooth treatment involves minimal discomfort for the patient. “As applied to the body, I think it’s a great applica-tion of energy. It’s comfortable for the patient. Some of the devices are very painful for the patient. Some of the energy based devices are very painful to the patient,” Dr. Lorenc says.

PHYSICIAN FLEXIBILITY“For a variety of procedures that we’re doing now, there’s

really no right or wrong way to do them. There’s a lot of creativity with respect to combining procedures,” Dr. Buford maintains. “A good example is the neck procedures where we’re starting out with the ThermiTight and we use ThermiSmooth after. In the past, we just used one. There are people who are just using the ThermiSmooth and there are people who are just using the ThermiTight.”

“Personally, having both devices, I think that you get a one-two punch, and you get more efficacy when you combine them, because you’re heating the tissue in a little different manner,” Dr. Buford adds.

As a plastic surgeon, Dr. Buford feels he has “a little bit deeper insight into what can and cannot be achieved with devices.” That under-standing is critical, he says, “Because when it comes down to it, expec-tations are everything. You can’t promise your patient something you can’t deliver. If you do, you’re going to have unhappy patients and you’re not going to be able to build your practice clientele.” Certainly there are learning curves in terms of how the procedures are performed, and there’s always opportunity to modify the approach. “I’ve seen people per-form the procedures very differently with respect to depth, with respect to the heat energy they start with, the amount of contact time.”

Combination approaches are also important for Dr. Lorenc. “What I love to do specifically

on the face is that I use a combination of ThermiTight and ThermiSmooth. Once I finish with the ThermiTight—typi-cally about two, three weeks after that, my aestheticians do a whole sequence of ThermiSmooth on top of that,” he explains. “I think you potentiate the effect of ThermiTight and ThermiSmooth. It’s all about energy delivery, so we do the sequence of every two weeks, six treatments of ThermiSmooth after I finish ThermiTight and I think that gives a better result to the patient.”

“The most important factor in achieving optimal outcomes is realistic expectations. That applies to fillers, to toxins, to surgery, to anything,” Dr. Buford emphasizes. “Unfortunately, I think that a lot of times we’ll go to meetings and we’ll get wowed by technology and we’ll just blindly think that it works for everyone, that it’s going to achieve the same results that we see in the before and afters. That’s not the case. No device performs 100 percent, every time, out of the box.”

“The more you use the device, the more you learn how to push the boundaries with respect to greater duration time or greater contact time, higher energies, higher temperatures, and again, using combinations,” Dr. Buford explains. “As you

“THE THERMISMOOTH PROCEDURE FOR THE ABDOMEN IS A WONDERFUL APPLICATION,

WHICH CAN VERY EFFECTIVELY TIGHTEN THE SKIN TO A CERTAIN EXTENT, DEPENDING UPON THE PATIENT’S TISSUE QUALITY, THEIR AGE, THE DEGREE OF SKIN LAXITY. WITH APPROPRIATE PATIENT EXPECTATIONS, OVERALL, WE HAVE VERY HAPPY PATIENTS FOR THOSE PROCEDURES.”

–GREG BUFORD, MD


go on, you really learn how to really finesse the technology, and that’s really been the exciting part.”

Dr. Lorenc agrees that the ability to hone technique is beneficial. “We vary the penetration of the heat by adjust-ing the size of the electrodes on the surface, so the larger the electrode the larger the surface area, the deeper it goes within the tissue. You can melt fat with that. We address cellulite on the thighs, on the buttocks with ThermiSmooth,” he says.

“What I really enjoy is the dialogue between the vari-ous users with respect to how they accomplish what they accomplish, because anybody that thinks they’ve solved everything is kidding themselves. We really do have a lot to learn from each other,” Dr. Buford maintains. “If you learn day one exactly how to do the procedure 100 percent, quite honestly, that would be really boring,” he says.

JUST THE BEGINNINGThermi, “has all these advantages, so as a source of

energy I’ve incorporated it into my practice and it’s the number one energy based device that I use in my practice,” Dr. Lorenc says.

And today’s experience may just be the tip of the iceberg. “I do think that combination therapies are really where the aesthetic marketplace or the practice of aesthetic medicine is really heading. At least for those practitioners who are visionaries. There’s a lot of aesthetic practitioners who are just cut on the dotted line kind of practitioners that don’t expand the boundaries. Quite honestly, I think that’s bor-ing,” Dr. Buford says. “I think that the next five, 10 years we’re going to see a real revolution with respect to how we’re utilizing combination therapy and the types of results we’re ultimately achieving for our patients,” he adds. n

EXPECTATIONS MATTER“I’ve identified what I can and cannot do and I think that’s critical,” Dr. Buford says. “If a patient comes in and they need a neck lift and they have so much tissue laxity that I know I’m not going to be able to affect a positive change, I’m going to tell them that. I don’t do neck lifts anymore, so I will refer them.” Dr. Buford

explains the patient’s need, the limitations or his available technology, and the benefit of surgery when he makes the surgical referral. “I tell the patient that if you look at the curve, they’re really outside of the curve of efficacy with respect to what I can achieve with this device alone.”

However, some patients will be satisfied with treatment that is not a “home run.” Some patients simply do not want surgery and are “willing to accept even a small modicum of change,” Dr. Buford acknowledges. “If you have patient like that, that understands, that is cognizant of what the limitations are, then you can use Thermi and you’re not going to get a home run result, but quite honestly, you may actually achieve a result that the patient is very happy with.”

“I’d say this applies really to any device,” Dr. Buford adds, “but the starting out with realistic expectations—understanding, again, the advantages, the disadvantages, the achievable outcomes is important.”

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Courtesy of Greg Buford, MD


It’s a very exciting time” in female pelvic health, says Knoxville, TN urogynecologist Jeffrey R. Dell, MD. “To some degree, we’re really at the frontier stage of using these modalities, lasers and radio frequency, in the pelvic floor to treat a range of conditions that really up until the last

three or four years was not part of a mainstream approach to female pelvic floor health.”

With the excitement comes some confusion, says Dr. Dell, “not only for physicians but patients, because there are so many different products coming to the market and so many different claims being made.” Nonetheless, Dr. Dell believes the focus on new technologies is positive.

“I think we’re going to continue to have the opportunity to enhance patients’ quality of life across a range of condi-tions that really significantly and negatively impact their quality of life, but with lower risk to essentially no risk with almost no recovery or downtime. That’s a positive thing,” Dr. Dell says.

Radio frequency (RF) delivery technologies, such as ThermiVa, are now emerging as important tools for support-ing female pelvic floor health.

“I think one of the things that’s helpful in terms of thinking about all of these different types of energy platforms is to look at the last 10-year history of plastic surgery’s and dermatol-ogy’s experience,” Dr. Dell says. He offers the analogy of facial treatments. “Those specialties would say that these various different energy platforms have different strengths. And while there is some overlap in terms of similarly of response that one type of energy platform may have with another, there are some significant differences regarding strengths of one energy platform over another.” Just as the approach for dealing aes-thetically with the aging process on the face may require a range of different types of energy sources, so might treatment of the pelvic floor require combination approaches.

Radio frequency is emerging as an important tool in the toolkit. “Radiofrequency has some tremendous benefits and strengths when it comes to dealing with laxity of the skin,” Dr. Dell observes. “It has a robust effect of allowing for some tissue tightening, because of its immediate and longer term effects on collagen leading to tightening of that skin. And so those applications in the pelvic floor would be for patients who are complaining of things being loose after multiple childbirths or their tissue is beginning to sag and doesn’t have the look and feel that it used to in the younger years. Radio frequency historically has tremendous strengths in that arena.”

For their part, CO2 lasers, “may best address the aging process with regard to dryness and the severe thinning of vaginal and vulvar tissue that is a part of the natural aging response after menopause, but also in some disease state conditions, one of which is lichen sclerosus,” Dr. Dell remarks.

Urinary incontinence is a concern for many women. Earlier interventions, such as slings, mesh, and surgical implants, have been associated with litigation, Dr. Dell notes. This has led to, “a desire on the part of the popula-tion to have noninvasive, nonsurgical procedures that might improve quality of life with less risk and recovery.” Energy-based procedures have the opportunity to excel in this area.

As aesthetic specialists, gynecologists, and urogynecolo-gists continue to evaluate the technologies and provide treatments, there is opportunity to better elucidate the role of each type of technology. In the future, Dr. Dell hopes to see more standardized terminology that can be understood across the spectrum of different specialties of physicians so that doctors are speaking the same language. He’d also like to see some more objective, rigorously designed trials of

THERMIVA: AN IMPORTANT DEVELOPMENT FOR FEMALE PELVIC HEALTH

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the various devices.At his New York plastic surgery practice, Z. Paul Lorenc,

MD says that ThermiVa radio frequency treatment is very popular and effective. ThermiVa is a non-invasive, non-abla-tive, non-surgical treatment that is performed in the office with no anesthesia required.

In Dr. Lorenc’s office, aestheticians administer the treat-ment. There is no downtime associated with the ThermiVa procedure.

Dr. Lorenc notes that ThermiVa treatment addresses a range of vaginal symptoms, “whether post-menopausal or post-child birth. Whether it’s laxity or lack of lubrication and so forth.” He says he has “very happy patients.”

“There is no question that these different energy plat-forms are doing some fantastic things to enhance the quality of life of patients,” Dr. Dell says.

AN OPPORTUNITYPhysicians have an opportunity both to learn more

about the activity of available systems and to enhance the level of service they provide their female patients. “While new treatment modalities in the female pelvic floor are exciting and enhancing the quality of life of our patients, it is important that we continue to develop structure and treatment protocols with science to back them up,” Dr. Dell says.

The demand for understanding the technology and providing treatment is significant, suggests Dr. Lorenc. “I think the market’s huge. I don’t think—I know the mar-ket is huge. Consider all the women that are on hormone replacement or need hormone therapy, imagine if that can be taken away by a procedure. I think that would be fantas-

UPDATE ON FEMALE PELVIC HEALTHThe exciting potential for non-surgical, device-based treatment of the female pelvic floor notwithstanding, Dr. Dell offers a word of caution: “The female pelvic floor can be fairly complex. There currently is a blurring among these procedures between what’s being used for aesthetic changes of the female genitalia and pelvic floor versus what’s being used to attempt to try to enhance the sexual experience and feeling of the tissue, whether or not it changes in looks.”

Adding an additional layer of complexity, “aesthetic and sexual response enhancing procedures overlap with true pathology or disease states where we’re dealing with significant incontinence issues, significant prolapse issues and potentially even a condition like lichen sclerosus which is a disease process of which one to two percent of patients can develop squamous cell cancer.”

Anyone assessing and treating patients must understand female pelvic floor health and be prepared to recognize their limitations. “I think the critical point here is that it’s important for non-gynecology based physicians who are using these platforms to carefully assess which patients are good candidates for these newer procedures and which patients need specialized or subspecialized evaluation before proceeding,” Dr. Dell offers. Not only is it important for the patient’s health, but it also avoids treatment dissatisfaction. “Without proper assessment and treatment planning, patients may not respond very well to the energy platform that is better suited for mild laxity or for a very mild type of incontinence and not for more a severe situation.”


tic.” Practices can capitalize on patient demand via internal marketing, he believes. And support from the companies to

educate the public and the medical community is, “going to potentiate this several fold,” he predicts. n

“RADIOFREQUENCY HAS SOME TREMENDOUS BENEFITS AND STRENGTHS WHEN IT COMES TO DEALING WITH LAXITY OF THE SKIN. IT HAS A

ROBUST EFFECT OF ALLOWING FOR SOME TISSUE TIGHTENING, BECAUSE OF ITS IMMEDIATE AND LONGER TERM EFFECTS ON COLLAGEN LEADING TO TIGHTENING OF THAT SKIN. AND SO THOSE APPLICATIONS IN THE PELVIC FLOOR WOULD BE FOR PATIENTS WHO ARE COMPLAINING OF THINGS BEING LOOSE AFTER MULTIPLE CHILDBIRTHS OR THEIR TISSUE IS BEGINNING TO SAG AND DOESN’T HAVE THE LOOK AND FEEL THAT IT USED TO IN THE YOUNGER YEARS.”

–JEFFREY DELL, MD


I’m a skeptic at heart,” says Z. Paul Lorenc, MD. “That’s just me. I need some science. Whenever I purchase a piece of equipment, I always do my homework.” So when he was considering the Thermi platform for his New York City prac-tice, he reviewed the research and was confident about the

theory behind the technology. What sold him on the system was the positive feedback from peers. “I spoke to a couple of people who had the devices, and they were all in favor,” he says. “It does exactly what it was said to deliver, if not more.”

Dr. Lorenc purchased the system and started to intro-duce Thermi by rolling out the ThermiTight procedure. For more than two years now he has offered ThermiTight, ThermiSmooth, ThermiVa, and ThermiRase.

ThermiRase is a unique technology, he says, that uses radio frequency to enervate muscles, similar in many respects to the action of injectable neuromodulators. However, the device offers some specific benefits over injectables and may be poised to gain prominence in the near future, Dr. Lorenc predicts.

WHOLE BODY/WHOLE PRACTICE The Thermi platform, “really has integrated well into my

practice,” Dr. Lorenc says. “I know that it’s a bold statement, but it almost changed the character of my practice when it comes to facial rejuvenation. That’s because it broadens the spectrum of what I can do.” As a surgeon, Dr. Lorenc sees benefit to being able to offer a device-based treatment to those patients who are not quite ready for surgical interven-tion, such as a face lift, or those who want improvement but simply won’t agree to surgery.

Alternatively, the device can freshen up a patient who has had surgery in the past but is beginning to see new laxity. Consider a patient who had a face left roughly 12 years ago who recently underwent ThermiTight in Dr. Lorenc’s office, “just to tweak or tighten the skin and the jowls and the neck.

It works both ways.” As Dr. Lorenc notes, ThermiTight is appropriate for, “patients who are not quite ready for a surgi-cal approach and patients post-surgically where you can aug-ment the results and maintain their surgical results.”

He also likes that he can use the device to expand the treatment options for a given patient. “Just yesterday I did ThermiTight on a patient on both the knees, and also on the face.”

The Thermi platforms all provide a high degree of opera-tor control. “The thing that attracted me to this system and that continues to get me excited and the reason that I do so many Thermi procedures, is that the feedback loop gives me control,” Dr. Lorenc says. Depending on the platform being used, an infrared camera measures the surface temperature or a thermocouple measures the temperature underneath the skin when using the probe. “With ThermiTight and ThermiSmooth there is a measurement of the temperature where the device gets the skin to a particular set tempera-ture. I like that control because it’s not a just a haphazard way of delivering energy,” he adds.

Now comes ThermiRase, which further expands the types of treatments that Dr. Lorenc can offer. The treatment deliv-ers targeted radiofrequency energy to weaken muscles in the forehead or the platysma, with results similar to that from injectable neuromodulators. “As a surgeon I’m very familiar with the enervation of the platysma and the corrugators and procerus, plus, I do a lot of anatomical studies. I am very much in favor of using radio frequency to achieve enervation of the muscles.”

Dr. Lorenc says he especially likes the results using ThermiRase on the neck. “I love using ThermiRase for the platysma. For the medial platysma, specifically, in combina-tion when I do ThermiTight to the neck.”

ThermiRase treatment is technically driven. The duration of effect depends on the proper placement of energy and

THERMIRASE: RF TARGETING FOR ENERVATION AND WRINKLE REDUCTION

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the total energy delivered. The physician maps the nerve prior to treatment and determines a treatment plan. The probe is inserted and applied to the nerve; placement is verified by stimulating the nerve. Dr. Lorenc predicts ongo-ing training and education to allow more physicians to adopt the procedure.

The duration of effect is much longer than with injectable neuromodulators, Dr. Lorenc reports. “I have a patient who I did a ThermiRase treatment close to two years ago. I did a glabella treatment in the D-11 and she maintained the cor-rection for two years now. She still has the correction. She’s

still better off than baseline at two years, which is pretty impressive.”

EXPANDING OPTIONSEven when he or she presents to

a surgeon’s office, a patient is not necessarily convinced of the need for surgery. “Every time the patient comes in, even if they’re coming in for a face lift, the first question is, ‘Is there anything else you can do out-side of surgery?’” Dr. Lorenc says. “That’s just a natural. Obviously that’s part of the discussion.” It’s in those discussions—ascertaining the patient’s concerns and their treatment goals—that the surgeon can best understand the patient’s need and the right course of action to balance efficacy, downtime, and costs. But that’s not to say that patients don’t need to come to the conversation informed of their options.

“We do internal marketing obvi-ously to our patients,” Dr. Lorenc notes. For a platform like Thermi

that offers multiple platforms to address a wide range of aes-thetic concerns, patients benefit from knowing their options. ThermiRase is not widely promoted to the public just yet, so internal messaging to patients is helpful. It sets the stage for a frank discussion between the patient and surgeon.

“Now, certain patients, obviously, are just candidates for surgery—not candidates for non-surgical,” Dr. Lorenc says. With advancements in minimally- and non-invasive inter-ventions, “this has been a moving base,” he adds. Thermi has become a go-to in the minimally-invasive realm for his patients. n

“I HAVE A PATIENT WHO I DID A THERMIRASE TREATMENT CLOSE TO TWO YEARS AGO. I

DID A GLABELLA TREATMENT IN THE D-11 AND SHE MAINTAINED THE CORRECTION FOR TWO YEARS NOW. SHE STILL HAS THE CORRECTION. SHE’S STILL BETTER OFF THAN BASELINE AT TWO YEARS, WHICH IS PRETTY IMPRESSIVE.”

–PAUL LORENC, MD


I’ve long been a proponent of the liquid facelift—made possible with the emergence of injectable neutrotoxins and fillers,” says Houston dermatologist Suneel Chilukuri, MD. By adding energy-based devices to address skin tex-ture and pigmentation, aesthetic surgeons have been able

to address three of the four Rs of rejuvenation: Relaxation, Revolumization, and Resurfacing.

Until now, a safe, reliable non-surgical approach to the

fourth R has remained elusive: Redraping. With the intro-duction of Silhouette InstaLift, Dr. Chilukuri says, aesthetic physicians can finally redrape the skin and truly optimize minimally-invasive, non-surgical rejuvenation.

A NOVEL APPROACHSilhouette InstaLift is a suture lift. The sutures have tiny

cones that are comprised of poly-L-lactic acid (PLLA) and polyglycolide/L-lactide (PLGA). PLLA is well-known to aesthetic physicians, as it has long been a component of certain suture materials and is the basis for an injectable filler product, Dr. Chilukuri says.

To place the sutures, a small puncture is made in the skin with an 18-gauge needle. Through this puncture, the suture is threaded and is then manually shifted, tug-ging the tissue taut to create an instant lift. Noticeable results are immediate.

For Washington, DC laser sur-geon Tina Alster, MD, the InstaLift standouts from other technolo-gies. “The InstaLift literally lifts the skin rather than simply ‘tighten-ing’ it (as can be achieved with other devices such as Ulthera and Thermage RF). As the sutures are absorbed and incorporated into the skin, the skin quality and der-mal volume is improved by the stimulation of collagen produc-

SILHOUETTE INSTALIFT: THE ABILITY TO NONSURGICALLY REDRAPE FACIAL TISSUE

““IN ADDITION TO HAVING THAT IMMEDIATE LIFT, YOU HAVE A LONG-TERM SOLUTION THAT

OCCURS BECAUSE AS THE PLLA BREAKS DOWN, IT STIMULATES THE FIBROBLASTS TO GROW NEW COLLAGEN…WITH NEW COLLAGEN FORMATION, THE SKIN LOOKS MORE TAUT, IT LOOKS MORE HEALTHY, AND PATIENTS GET THIS GLOW.”

–SUNEEL CHILUKURI, MD


tion—similar to the clinical effect of nonablative lasers and filler injections,” she says.

“In addition to having that immediate lift, you have a long-term solution that occurs because as the PLLA breaks down, it stimulates the fibroblasts to grow new collagen,” Dr. Chilukuri explains. “With new collagen formation, the skin looks more taut, it looks more healthy, and patients get this glow.” Patients see continued improvement over several months following treatment.

The entire procedure takes about an hour, including numb-ing and patient counseling/post-op instructions. There is no downtime.

“Our patients have been thrilled with the immediate change that they see,” Dr. Chilukuri says. He notes that an occasional patient may develop a bruise at the insertion site, but this is not the norm.

EXPANDING OPTIONSAs aesthetic interventions have become less invasive, more

accessible, and associated with less downtime, they appeal to a wider array of patients. This includes younger patients, seeking to address signs of aging early on or to prevent them altogether, Dr. Chilukuri observes.

“I’m thrilled that we’re able to address all four of the R’s

that we’ve talked about for several decades now,” Dr. Chilukuri says. In his practice, the Silhouette InstaLift is performed in conjunction with fillers, toxins, and/or laser, depending on the patient’s specific needs.

The ability to redrape the skin can be especially beneficial for younger

patients, Dr. Chilukuri maintains. Patients in their mid-40s to early 50s often are, “just starting to get that little bit of sagging near the jowls. I can now improve the actual skin positioning to strengthen the jaw line, recreating that sharp mandibular angle.”

“I recommend InstaLift for patients with mild to moderate laxity of the cheeks and mandible/upper neck whose con-dition is not severe enough to undergo a surgical lift or in those who do not desire surgery,” Dr. Alster agrees.

The rapidity of the treatment and the lack of downtime seems especially attractive to younger patients.

With that said, Dr. Chilukuri points out that he uses the InstaLift across all age groups. Older patients who are can-didates for surgery but wish not to have it can see some worthwhile improvement with InstaLift.

THE FULL PACKAGEDespite a slew of minimally invasive aesthetic advance-

ments in recent years, “what we’ve not been able to do is actually re-drape or reposition the face,” Dr. Chilukuri says. “We actually have a solution for that now.”

His experience administering InstaLift and his patients’ reaction to the new treatment have both been positive. “Our patients are incredibly satisfied,” he says. n

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Courtesy of Suneel Chilukuri, MD

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