Sublative rejuvenation

devices2Sublative rejuvenation

Fractional radiofrequency for skin rejuvenation and tightening, as well as for scars and stretch marks, can offer minimal complications for skin of colour, writes Dr Ines Verner


People with darker skins age differently, developing volume loss and a loss in laxity, with less surface wrinkling than Caucasians. Ageing indicators include melolabial folds, neck folds and pigmentation. Skin tightening is extremely difficult to document, to photograph and to show results—even with the best of imaging. This is especially difficult in skin of colour.

The current industry focus is to use combination approaches. We’re using toxins, fillers, peels, dermabrasion and cosmeceuticals. So if you’re looking for one single device that works brilliantly for everything, it doesn’t exist.

However, we can’t afford five devices in our office. We need to make intelligent choices to provide a gradual and complete rejuvenation. A device also depends on many things—distributor, technology, cost to you and cost to the patient.



Fractional lasers have revolutionised the industry. With their patterned microscopic thermal wounds in the skin while the surrounding tissue is spared, we see much less downtime and fewer complications than with traditional CO2 resurfacing.

I’m a big fractional laser user. I use the CO2 laser, particularly for working with lighter skin types.  For darker skin types, I prefer to use fractional radiofrequency (RF) technologies which better address the problems that darker skins pose, such as sagging, mild surface irregularities and dyspigmentation. Additionally, there is virtually no risk of complications.

So what is the concept behind fractional laser or fractional RF? We’re leaving behind healthy tissue to speed up the healing process. When light is used to rejuvenate the skin, high energies are needed to achieve optimal results. For patients with lighter skin, this is not so much of a problem. But in the darker skin types, there is a much greater risk for complications.

As RF can give us remarkable results of tightening and rejuvenation even at lower energies, we can safely and easily use this technology in darker skin types. With RF—even at low energies—we see gradual skin tightening and lifting with simultaneous improvement of surface irregularities. There’s a huge amount of clinical data available and it’s one of the newer treatments for darker skins.


Sublative rejuvenation

Devices such as the E2 by Syneron Medical have two treatment heads. The sublative rejuvenation head provides bulk heating in the dermis while also fractionally heating the epidermis. The other treatment head is called Sublime, and combines RF with infrared light for even deeper and more pronounced heating of the tissue.

Sublative RF is a unique approach as it offers us a mild approach to rejuvenation.  Following treatment, patients are only red for a day or two; they can apply make up and leave the house.

After three to five treatments, remarkable clinical results can be seen. This is due to optimal dermal stimulation of new collagen production, with the energy delivered through multi-electrode pins.

As only around 5% of the epidermis is disrupted with this treatment, the risk of post-inflammatory hyperpigmentation (PIH) is very low, even with darker skin types. Also, we’ve got more dermal impact and less epidermal impact which leads to tissue tightening.  There is also a higher tolerability as the treatment is not painful and a great safety profile. There is very little risk of complications.

As device physicians, we need to understand the mechanisms of action.  Just because we bought a laser three years ago, it does not mean we don’t need to upgrade our clinic or buy a new technology.

The machine I use now has pins and electrodes, and delivers RF in a homogeneous fractional manner. It’s a very controlled treatment and easy to operate. As with all of the new technologies, they have smart-screens and do most of the work. But when we’re working with darker skins, we have to choose our energies.

This is critical—ask yourself, “Can I delegate this treatment?” Yes, you can. In my experience, the E2 from Syneron is a very safe technology and can be delegated. However, I do check the energy settings before each treatment in my clinic.

Impedance is a new term associated with RF. It’s the resistance in our skin to electrical energy. The device measures the tissue impedance during treatment and momentarily adjusts the delivered energy to the skin.  In this way the amount of delivered energy is always right.


Combination treatments

Almost every practitioner is using combination treatments in one way or another. There are a lot of people performing microneedling, with controlled studies documenting its use. Transepidermal delivery systems are gaining interest, as well as using under-eye devices with cosmeceuticals for home use.

The newer approaches for skin tightening are now all combination devices. The E2 uses a combination of infrared and RF, so it has two technologies combined in one. Manufacturers are trying to create a channel, trying to go deeper and trying to protect the epidermis. There are good results, but we do have to be cautious with our treatments.

The choice of treatment is based on many variables. What is your patient requirement? What is your skill? What device do you already have in the office? Choose something to augment or change. Don’t get carried away and buy something very similar. Look at going into a completely new area.

Think about the budget. This is often overlooked. We’re all living in a utopia where patients arrive with their credit card and say, “Do what you want.” I don’t have those kinds of patients. It’s vital to be able to give a viable economic treatment. We have to consider four to eight sessions of these treatments, so we have to price them appropriately.

We have to be realistic about tightening and rejuvenation. This is more pertinent to darker skins—results seen in Caucasians are brilliant, but in darker skins we are at a disadvantage. It’s an individual combination regimen because skin of colour is a challenge. But we’re in an era of new technology, so we can explore new devices. It’s about being open-minded and aiming to really make a difference.

Dr Ines Verner is a Dermatologist & Immediate Past President of the Israel Society of Dermatologic Surgery.  She is manager & owner of The Clinic of Dermatology & Aesthetics in Tel Aviv, Israel


Author: bodylanguage

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