American Academy of Ophthalmology Web Site: www.aao.org
Fresh Oculoplastics Technologies: The New Face of Cosmesis
Thermal injuries. Abraded skin. Barbed sutures and cranial holes. Sound like trauma? No—it’s facial rejuvenation! And more ophthalmologists may be accessing these new technologies.
As Baby Boomers confront their first serious wrinkles, and younger patients seek to keep the earliest signs of aging at bay, the facial rejuvenation business is flourishing. New oculoplastics technologies, with their promise of less downtime for the patient, are one of the driving forces. For ophthalmologists, the prospect of adding more fee-for-service procedures to their practice—and the potential to provide follow-up rejuvenation services to their patients for many years to come—are making cosmetic procedures more attractive than ever before.
But many of these new technologies require a substantial capital outlay. Moreover, with the less invasive procedures, the cosmetic improvements tend to be subtle, rather than dramatic. The durability of results also is variable, in some instances lasting less than a year for a procedure that may have cost the patient several thousand dollars. These realities underscore the importance of choosing equipment wisely and managing patient expectations—both of which require an understanding of each procedure’s potential benefits and limitations.
Several oculoplastics experts shared with us their impressions of some of the most popular new technologies. The procedures range from the widely advertised “thread lifts” to a variety of micro-injury delivery systems: lasers, radio frequencies, pulsed light, infrared and sonic energy.
Contour Threads (Surgical Specialties) are nonabsorbable barbed sutures that can be used to lift and fixate sagging brow, cheek or neck tissue. This in-office procedure takes about an hour to perform and requires only a local anesthetic and sedation as needed. The clear polypropylene “thread” is inserted through a hollow needle into the subcutaneous tissue along the vector of lift and fixated to deeper tissue.
After the needle is removed, the physician gently massages the placement area. The tiny barbs open in an umbrellalike manner, catching and lifting the tissue as the physician gently pulls the thread upward. The patient participates in the procedure by suggesting more or less lift before the thread is tied off. Most procedures require placement of at least four threads. Over the next weeks, collagen grows around the threads and secures the elevated tissue. Slight overcorrection is desirable because the tissues will drop slightly in the first one to two months.
Patients may experience some discomfort, redness, swelling or bruising after the procedure. But most people can return to work and to their usual activities within a few days to a week. Complications of thread lifts are uncommon but may include thread rupture, skin irregularities, asymmetry, skin puckering or infection. Some patients may experience a feeling of tightness or pulling from the threads. Others may report that they can feel the threads under their skin.
Fast and easy, but before you know it . . . John W. Shore, MD, an oculoplastics surgeon in Austin, Texas, said the thread procedure is quick, doesn’t have a long learning curve and can achieve an early desirable result. But he’s not sure about its staying power. “I don’t think the long-term benefit is going to be there,” he said. “A patient spends two or three thousand dollars to have the threads inserted, and it will look great for maybe three or four months. But after a year and a half, it does what most suture material does—it tends to cut through the tissue a little bit, and the effect is lost.”
Dr. Shore added that he has seen patients whose threads were placed too close to the skin, causing small areas of irritation to develop. The badly placed threads had to be surgically removed, a process that is difficult because of the barbs.
Erin L. Holloman, MD, an oculoplastics surgeon in private practice in Oklahoma City, said she and her partner, Sterling S. Baker, MD, don’t tend to use the threads in their practice because of the threads’ complication risk profile and expense, as well as questions about the long-term results. Christine C. Nelson, MD, an associate professor of ophthalmology and visual sciences and associate professor of surgery, University of Michigan, Ann Arbor, also expressed concern about the long-term viability of Contour Threads.
Endotine absorbable fixation devices (Coapt Systems) are being used in brow, forehead and midface lifts. The Endotine devices are bioabsorbable implants with an anchoring post and a thin fixation platform containing multiple tines. A disposable drill bit, which fits most handheld drills, is used to drill the anchoring hole. The implants are then secured into the bone with an insertion tool, and the tissue is lifted and secured on the tines.
The multitined implants distribute tension across several points, enabling the physician to accomplish a secure, adjustable soft tissue fixation within a few minutes. The procedures are performed under local anesthesia and may not require any endoscopic equipment, although some surgeons do incorporate the implants into their endoscopic surgeries. The Endotine fixation device is absorbed within about six to nine months.
In an Endotine transblepharoplasty brow lift, the surgeon goes in through the conventional upper eyelid incision. A three-tined implant is anchored into a 3-mm drill hole in the cranium. The procedure is contraindicated in patients with fragile or very thin bones, a thin atrophic scalp, allergy or sensitivity to plastic biomaterials, or infection. Side effects may include tenderness and palpability over the device. Complications are uncommon but may include dislodging of the tissues before the healing process is complete.
Tine and tine again. Dr. Holloman has found Endotines to be a good addition to the available options for brow lifting. “I mostly like that it is virtually impossible to overcorrect a patient and give them an unnatural ‘surprised look’ with the devices. However, with the different device types, patient selection is important. The transblepharoplasty device allows an ophthalmologist to go through a familiar incision to do a brow lift, as opposed to having to use an endoscopic approach or some other approach that’s not as familiar. But that particular device is not suited for all degrees of brow ptosis.”
Dr. Shore has used Endotines for more than two years, especially in endoforehead lifts and endobrow lifts. “They allow you to achieve good fixation with a device that is internal, so there doesn’t have to be externalized skin removed,” he said. “It’s quick and easy, and we know that it lasts.” He added that drilling the hole is safe because the drill bit cores out the bone only to a certain depth. The device is then just popped into place.
Dr. Nelson also has used Endotines with good results. “It’s really a matter of the surgeon’s preference,” she said. “But I like them and have used them for several years.” She noted that the implants are expensive and that some patients complain of tenderness over the site, especially when wearing a headband or cap or when pulling on a turtleneck.
In the perennial search for cosmetic rejuvenation of skin surface and tone, several new lasers or laserlike devices have been introduced. They range from nonablative procedures to microresurfacing techniques that give the skin a light peel. All are in-office procedures. Compared with CO2 laser ablation, the new treatments offer modest cosmetic improvements with limited durability. These rejuvenation procedures are aimed at people between the ages of 30 and 60. After age 60 or so, a surgical facelift is usually necessary to achieve the desired results.
You mean I can’t get a 10? Dr. Baker, an assistant clinical professor of ophthalmology at the University of Oklahoma, uses a scale of 0 to 10 when discussing the effectiveness of current facial rejuvenation methods. In his scale, moisturizing products rate a zero because they only hydrate the skin, and a “wrinkle eraser” (which doesn’t exist) would rate a 10. The best nonsurgical results rate a 7 or 8 and can be achieved through a deep chemical peel, deep dermabrasion or an ablative laser procedure. Most noninvasive procedures rank in the 3 to 5 range. Superficial peels and microdermabrasion, he said, may be as low as 1 or 2.
The bottom line, said Dr. Shore, is that all facial rejuvenation techniques work by creating an injury, and then the healing process tightens the skin. “The greater the injury, the better the effect—but the longer the downtime. Everyone is looking for something that will achieve the good effect but without the downtime.”
Here are a few of the new facial rejuvenation technologies introduced in the last several years:
Thermage radio frequency. Thermage procedures (Thermage) use radiofrequency (RF) energy to heat the deep dermis to stimulate collagen growth and produce skin tightening. Known formally as radiothermoplasty, Thermage achieves moderate skin tightening and “lift” in the mid- and lower face and forehead. Tissue tightening continues for two to six months after the procedure and improves with two or more treatments. Unlike laser technologies, Thermage works equally well on all skin types.
In a Thermage procedure, the RF energy is delivered uniformly to the deep layers through a treatment tip while a cryogen cooling spray is applied to protect the epidermis. A treatment grid is used on the face to prevent treatment overlap and to ensure that all targeted tissue has been treated. Thermage typically produces mild discomfort and requires only an application of an anesthetic cream to the skin (although some patients may need a mild pain medication or sedative). The procedure takes one to two hours to complete and results in virtually no patient downtime afterward. Side effects, such as redness, swelling, bumps or blisters, are uncommon and typically disappear within a few days.
Dr. Holloman said the effects of Thermage are subtle and not as long lasting as surgery or a more aggressive resurfacing procedure would be. “We explain to our patients that these procedures won’t produce results as dramatic as those achieved with surgery and that they may need to be done every two to three years. The advantage is no downtime, bruising or scars.” She added that the company has received FDA approval to introduce a new Thermage procedure that can be used on the eyelid and in the periorbital area.
Syneron intense pulsed light. The Syneron IPL device (Syneron Medical) combines RF energy and intense pulsed light (IPL). The two technologies have a synergistic effect. By heating the tissue and reducing its impedance, the IPL enables the RF energy to enter the areas of lower impedance. This distribution of RF energy, in turn, compounds the heating effect of the intense pulsed light.
“The energy goes around in a loop and goes down and heats up the skin,” Dr. Shore said. “You cool the skin surface while delivering the radiofrequency energy to the deeper tissues. This creates heat in the deeper collagen and supposedly tightens it.” He describes the cosmetic effect as modest.
Fraxel laser. The Fraxel laser (Reliant Technologies) relies on fractional photothermolysis to smooth out wrinkles and improve skin texture and tone. The technique creates thousands of microscopic zones of thermal injury, or microthermal zones (MTZs). MTZs are columns of coagulated tissue, 70 to 100 µm in diameter, that extend through the epidermis into the deep dermis. Within a few weeks, the coagulated tissue has been eliminated and replaced with healing tissue and new collagen.
Fraxel treatment of the face and neck takes about 15 minutes. Patients typically undergo four to six treatment sessions spaced two to four weeks apart, and optimal cosmetic results are achieved in two to three months. An anesthetic gel is used on the face, and oral pain medication is given if needed. Patients typically feel warmth or tingling during the procedure and have a sunburnlike feeling and appearance for several hours afterward. The skin may have a pinkish tone to it for five to seven days.
Dr. Shore noted that the Fraxel procedure has gained some popularity recently. The main advantage over the CO2 laser is that it can deliver the energy to the deeper layers of the skin without having to remove the surface layers.
Erbium laser. Sciton’s erbium laser provides a light skin resurfacing, or microresurfacing. Dr. Holloman said these “micro” laser peels produce the greatest patient satisfaction in her practice. “I do a series of three to four procedures, eight to 10 weeks apart,” she said. “The laser allows me to resurface in microns, so I can control the depth of the resurfacing. Depending on the patient and their stated goals, I can make it more or less aggressive.” Dr. Holloman added that both the erbium laser and the Fraxel laser have shown promise in decreasing periorbital wrinkles and in tightening up the aged skin around the eyes and on the eyelid.
She uses globe protectors when performing these more aggressive resurfacing procedures around the eyes. Patients may need oral pain medication, and they need to be informed about possible redness and swelling afterward and the need for a few days’ downtime before returning to their regular activities. The resurfacing procedures carry a small risk of hyper- or hypopigmentation, especially when used in patients with the darker skin types.
Titan infrared energy. The Titan device (Cutera) relies on infrared energy delivered in very long, slow pulses. Because the lower-energy pulses heat up the tissue slowly, the procedure is not painful and does not affect the skin surface.
“You can see an immediate tightening effect in many patients,” Dr. Shore said. “But because you can only heat the tissue so quickly, and the energy has to be delivered so slowly and in long pulses, multiple passes have to be performed in the same area, and it takes about an hour to treat the face. But patients can put their makeup back on and go back to work afterward.”
Dr. Shore noted that the long-term results with the Titan device are unknown and that repeat treatments will probably be necessary to maintain the benefits.
Vibraderm sonic energy. Vibraderm has developed a sonically driven device that produces microdermabrasion. “The older dermabraders actually did abrade,” Dr. Baker said. “They used a particulate matter that was drawn across the skin by a vacuum and actually removed the outer layers of epidermis. Vibraderm does it through vibration.”
“Vibraderm can deeply remove the stratum corneum, and it has some potential for collagen stimulation,” Dr. Holloman added. She noted that Vibraderm is less messy than other types of microdermabrasion and better received by the patient.
“You don’t have the loud vacuum, with debris in the air and patients having grit all over them. The procedure does tend to create softer and a little smoother skin. Our patients have liked it, and we use it over the full face and definitely around the eyes.”
Patients’ Choice: Quick Results or Long-Term Commitment?
The key to patient satisfaction with these skin rejuvenation procedures is to make sure that patients have realistic expectations going in. A frank discussion of what a particular treatment can and cannot do is essential. Patients love the idea of a minimally invasive, low-risk, fast-return-to-work procedure, Dr. Shore said.
But everyone needs to understand that there is always a trade-off: The more aggressive the procedure, the more noticeable the results—but the longer the downtime. The less aggressive the procedure and the faster the recovery time, the more subtle—and often more fleeting—the cosmetic improvement. When patients have a realistic idea of what to expect, they are usually happy with the results.