DAY 3 - DAILY SUMMARY
June 13, 2021

What Works and What Doesn't

Ronald Moy, M.D.

Dr. Moy provided us with his expert opinion on which cosmetic procedures seem to be more effective than others. He began his talk advising dermatologists to “be skeptical” about new devices and treatments in the cosmetic world. We should also approach publications and anecdotal success stories with caution, as negative results are often not published. We should focus on clear photographic results.  Procedures that appear effective histopathologically may not show as clear success when looking at before and after photos. 
 
Regarding various treatments, Dr. Moy believes that ablative lasers, such as CO2 and erbium lasers are the most effective for tightening the skin, but are associated with downtime. He has reduced how many facelifts and blepharoplasties he now performs because of the success of laser resurfacing. Regarding PRP for skin rejuvenation, it appears to be low risk, but has <50%improvement for fine lines and wrinkles. It has high satisfaction and may work for androgenetic alopecia, but the results lack standardization of procedure. Microneedling radiofrequency does not seem very efficacious with older devices and can be uncomfortable, but newer devices offer more promise. 
 
Regarding other cosmetic procedures, skin threads seem to work for variable amount of time, and appear to rely the most on technique and appropriate patient selection. Fillers work, but more is not better.  Neuromodulators are also on Dr. Moy’s list of “things that work” but are also dependent on injection technique. There are newer products coming on the market that may last longer.

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Lasers

Victor Ross, M.D.

Dr. Ross gave a great overview of the history and development of laser technology over time. Laser and light-based devices can target pigment, contour, and texture. Easier indications for treatment include hair, telangiectasias, tattoos, and lentigines in lighter skin. More difficult-to-treat conditions include melasma, diffuse warts, flushing, vascular lesions in darker-skinned patients, skin-tightening, acne, leg veins, and neck rejuvenation.

For facial rejuvenation and acne scars, non-ablative fractional, ablative fractional, conventional resurfacing lasers are best, although there are more side effects including infection with conventional resurfacing. Visible light technologies target dyschromia and vessels, however wrinkle improvement is a bonus effect. For vascular indications, KTP, PDL, and IPL are best, however, alexandrite, 810 or 980nm diode, and Nd:YAG lasers have efficacy as well (although with more risk of dermal damage). For tattoos, the Q-switched 532nm, ruby, alexandrite, and 1064nm lasers work best. For epidermal pigmented lesions, the Q-switched 532nm, ruby, and alexandrite all work well, however risk of post-inflammatory hyperpigmentation (PIH) must be considered (especially with the Q-switched 532nm). Long pulsed 532nm KTP and IPL (tougher to get lighter lentigines) are slightly less effective but still work well. The 810nm diode and long-pulsed alexandrite can also be used. Persistence and recurrence of lentigines must be discussed with patients.

​Future advances with laser technology include development of a 1726nm laser for uses such as acne and sebaceous hyperplasia, as there is slightly more absorption with fat than water. Accessorizing lasers with lamps with polarization is helpful to visualize brown and red targets, and more modular systems may be seen in the future. Finally, nano-pulse stimulation uses electric energy to thermally clear cellular areas and spare non-cellular areas (regulated cell death), and may be a useful treatment for warts.

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Radiofrequency, Lifting, and Tightening Devices

Victor Ross, M.D.

Dr. Ross concluded with an excellent review of non-invasive devices for skin lifting and tightening including radiofrequency (RF) microneedling, high frequency ultrasound, cannula-based systems, and RF motion and stamping techniques. 
           
Highlights of the talk included a focus on microneedling with RF. Issues with this include but are not limited to an unknown needle depth, increased resistance to needle penetration with depth, variability in user pressure, delivery angle, and needs for more precise control of needle depth/penetration, energy delivered, speed of treatment, and more. Many RF needle devices reflect off the surface of the skin, and much force is needed for needle penetration. 

A few specific devices were discussed. Morpheus08 is a newer device which is able to penetrate to a depth of 4-5mm. The monopolar needle RF device called Agnes, with just 1-3 needles, may be useful in the undereye area bags, especially in younger patients. Newer microneedling RF devices have impedance control, which allows for consistent/uniform delivery of energy. Skin tightening modalities can be combined with lasers/light-based devices depending on the anatomic location, such as the CO2 laser, 1927nm, 1550nm fractional, IPL or KTP. This may offer patients additional improvement with issues such as poikiloderma, pigmentation, etc. 

​In conclusion, skin tightening devices do not work for everyone, however for some select patients are a good option.