Blending and Sequencing Considerations

4 Blending and Sequencing Considerations

Daniel R. Butz and Julius W. Few Jr.

Summary

This chapter addresses the benefits of combining three modes of noninvasive treatments (focused ultrasound, volume restoration, and laser resurfacing) to achieve optimal results. In the ideal patient, the results of this combination often resemble surgical results.

Keywords: focused ultrasound, volume restoration, laser resurfacing, ptosis, stacking, Fitzpatrick skin type, autologous, synthetic

Key Points

• The results of noninvasive approaches can approach surgical outcomes by targeting the three primary components of aging: volume loss, facial anatomy ptosis, and skin elasticity loss.

• It is vital to address at least two of these three primary components of aging for optimal nonsurgical blending to create a true synergy.

• When one combines the three modes of noninvasive treatment, one can apply less fluence with laser resurfacing and less volume with the given filler to achieve optimal results that are often close to those of surgery in the ideal patient.

• The ideal patient for stackable treatments to the face and body represents the man or woman in good shape with early aging changes, nonobese, and with at least one of the three aging components.

4.1 Introduction

Comprehensive care of the aesthetic patient relies on targeted treatment of all the given components that take away from a given individual’s aesthetic balance. Regardless of surgical or nonsurgical treatment, the goal remains the same: a balanced natural result. When we look at stacking nonsurgical therapeutic modalities, we approach it surgically to isolate the given component and find the best possible matching treatment. The use of focused ultrasound alone can deliver less-than-dramatic results, but the combination of facial fillers and laser resurfacing gives the patient a result that is relatively immediate. Also, given the lesser fluence required for laser therapy, the downtime is significantly less than that of tradition ablative laser resurfacing.1 The ability to create fine-tuned detail in the treatment of facial aging with combined nonsurgical modalities is very appealing to the discerning cosmetic patient, because treatments can be repeated as indicated to further enhance an already good improvement.

When looking at the sequence for the given treatments, we have found that the following sequence works well. We tend to do the focused ultrasound or related lifting technique first, followed by volume restoration, and then resurfacing, even if it is all done on the same day. The rationale relates to placing energy first, and then volume to “stretch” ptotic skin, which makes the laser resurfacing easier. In addition, regardless of synthetic or autologous filler substances, there is lidocaine present in the filler, making laser work less uncomfortable in the office setting. These treatments are readily tolerated with little or no oral sedation, and the typical treatment time is less than 2 hours for combined treatments. The ability to offer these treatments in the office means that patients can do so without the support of friends or family, so it is another level of discretion and privacy that the patient can really appreciate.

The major disadvantage of the nonsurgical approach has been the lack of “surgical longevity.” Although the given non-surgical approaches typically last 18 to 24 months, the combination or stacking of therapies results in a longer-longevity that approach surgical outcomes in some cases.² In addition, patients do not find the idea of upkeep difficult in most cases, because the interval is long between enhancement, given the long life of fillers, such as Juvéderm Voluma (Allergan, Inc.), and autologous fat (See Video 2.1). The use of an ablative laser adds to this package by having long-standing efficacy for facial resurfacing (see Product Index (p. 176)).

For stacking principles on the body, we have found the ability to use cryolipolytic fat reduction with skin-tightening radiofrequency technology to be highly synergistic in certain patients, especially those with significant loss in skin elasticity. The treatments are typically spaced out in their application by 2 to 4 weeks after the initial cryolipolysis session. The ability to use combined modalities for body contouring offers a legitimate alternative to the potential liposuction patient. This approach can even be utilized in the postliposuction patient with residual fat and/or skin laxity, allowing the plastic surgeon great fluidity in the comprehensive treatment of the cosmetic patient.

Cosmetic medicine is as much an art as it is science. One can use principles that are presented in the following text to combine other modalities in a safe, effective manner to deliver heightened results to the cosmetic patient.

4.2 Patient Selection

As with all patients in the plastic surgeon or dermatology practice, patient selection is the golden key in cosmetic medicine. The same is true for combination/stacking approaches to the cosmetic patient. To begin, patient expectations must align with the given combination. Patients must be willing to accept some uncertainty to the level of result and the prerequisite time to achieve a given result, which is typically 90 days or more. In addition, patients who do best with the stackable approach are those who are mild to moderate in their level of deficiency. For patients with more severe or end-stage change, the limits of nonsurgical treatments can be found, which we have learned this through our more severe patients who will only accept a nonsurgical solution regardless of the degree of gain.

The ability to add different modalities reduces the risk of not getting a response, which is sometimes seen with most non-surgical modalities in isolation. The “nonresponder” rate for a given nonsurgical modality is a particularly difficult concept for the plastic surgeon and an important consideration for patient selection. One reason why the “nonresponder” rate is difficult is that it may be much better for a patient to go to surgery if the plastic surgeon wants a degree of control and predictability while being willing to accept the surgical risk. The key is not “talking” the patient into a given approach but rather giving a spectrum of options for the patient to consider, from nonsurgical to surgical and everything in between. The patient is then able to look at the longevity of a given result, versus the risk, versus the predictability and efficacy. One can often be surprised by the level of patient satisfaction with a given combined surgical and nonsurgical result. We have all had patients after a very powerful surgical result who express only moderate satisfaction; although the same response can be true for a nonsurgical patient, it can also be the exact opposite. The nonsurgical patient may achieve 90% of the ideal result and be much more excited about their outcome than a different surgical patient who has 95% of their goal achieved, simply due to the level of commitment the patient has given to the process.

4.3 Technical Steps/Treatment Plan

The technical process begins with an assessment of the aging components, skin, volume, and ptosis:

• Skin

1. Fitzpatrick skin type.

2. Solar damage.

3. Wrinkle severity score.

4. Pigmentation irregularity.

5. Pre-existing lesions.

• Volume

1. Facial fat compartment volume loss.

2. Restoration vs. enhancement.

3. Autologous vs. synthetic.

• Ptosis

1. Facial.

2. Cervical.

3. Periorbital.

4. Perioral.

4.3.1 General Sequence: Face

1. Lift ptotic tissue before adding volume:

• Allows more effective, anatomic placement of filler.

• Avoids premature breakdown of filler or toxin by heat.

2. Fill volume deficit before skin resurfacing:

• Allows more effective resurfacing with lasers.

3. Lift ptotic tissue before or during resurfacing of the skin.

4.3.2 General Sequence: Body

1. Remove unwanted fat before using skin-tightening technology:

• Can be done in the same setting or in sequence.

• Allows for augmented skin redraping as the underlying soft tissue redrapes.

• Focused ultrasound and radiofrequency represent the current preferred tightening technologies.

2. Remove unwanted fat before using cellulite-eliminating technology:

• Breaks down and smooths some of the cellulite tissue.

• Can be done using surgical or nonsurgical strategies, such as laser lipolysis and cryolipolysis, respectively.

• Preferred cellulite management is through currently USFDA-approved modalities of laser-assisted or energyassisted subcision, done concurrently or staged in two settings.

3. Use cosmeceutical to aid in surface management of fine lines, wrinkles, and pigment:

• Lasers can be used as part of this strategy.

4. Postsurgical edema reduction and skin tightening can be enhanced by combined multipolar radiofrequency and magnetic field generation.

All stacking treatments are individualized. Ultrasound treatments target the submental area and jowling. Patients are instructed to take an oral sedative and a nonsteroidal anti-inflammatory drug (NSAID) prior to treatment. All patients are given the option of having a regional block performed 10 minutes prior to treatment. Full-face and lower-face treatments are performed over approximately 60 minutes (see Videos 2.9 and 2.10). Patients are treated with hyaluronic acid fillers, botulinum toxin, laser, or liposuction (see Video 1.1 and Video 2.3).

Volume deficits are corrected to 85%. Laser resurfacing is typically performed at 80% of the usual fluence. The resultant skin tightening and volume correction work synergistically to achieve a natural aesthetic result. Laser resurfacing consists of a deep and superficial component with feathering in certain areas for less advanced signs of aging or thin skin (upper/lower eyelids, neck).

The stackable technologies we most frequently use are the radiofrequency (Venus Freeze, Venus Concepts), Microfocused Ultrasound (Ultherapy, Ulthera, Inc.) and Cryolipolysis (Cool-Sculpting, ZELTIQ Aesthetics, Inc.) (see Product Index (p. 176)). Venus Freeze uses radiofrequency to heat the epidermis and dermis to cause thermal contraction. After cleaning the area, you take a baseline temperature. You then apply a thin layer of glycerin gel. The length and temperature used is based on the area being treated. The end temperature should be 39–45 °C. For optimal results, patients require 6 to 8 treatments spaced 1 to 10 days apart, and they frequently need maintenance treatments 3 times per year.

Microfocused ultrasound can heat the dermal layers and the SMAS layers of the face to cause contraction and skin tightening. Once the areas we are targeting are selected, the appropriate transducer is selected, based on the various areas of the face. The treatment area is cleaned and then marked using the transducer template. Ultrasound gel is applied, and the treatment is performed using Ulthera’s “amplify” settings as a guideline. Treatment sessions take 1 to 2 hours depending on the extent of the treatment. A single session typically gives results that last for 1 to 2 years.

CoolSculpting uses cooling technology to freeze fat cells and cause cell death. After discussing with the patient the areas they would like to target, you clean those areas and mark the middle portion of the adipose mound (see Product Index (p. 180)). The CoolSculpting templates are placed on the areas with the marks in the center. The temperature settings are adjusted to 60–75–60. A gel pad is applied to the area to protect the skin. Once the appropriate applicator is applied and the vacuum is turned on, the treatment lasts 1 hour or 1 hour and 15 minutes for the outer thighs. The vacuum is then turned off and the applicator is removed. The area should then be massaged for 2 minutes to help break down more fat cells. This treatment can provide a 20 to 25% reduction in adipose cells in the targeted area.