Dr Shirin Sammi-Fard discusses non-invasive approaches for face and body tightening
As a dermatologist I see an increasing number of patients in Germany who are not willing to go under the knife. They prefer a more natural look and less invasive methods. In my work, I don’t perform any kind of surgical operations or facelifts, what I offer are different treatment modalities using laser or lightsystems and radio- frequencies.
Thermage is a monopolar radiofrequency device, which uses a reverse thermal gradient. It is a seven mega-hertz RF generator, which includes a cooling module. It has the FDA clearance to treat lines and wrinkles on the face and on the body, and it’s the only device which also has FDA clearance for the upper and lower eyelid treatment. It also has the clearance for the temporary improvement of cellulite – though I don’t use it for this at all, just for contouring and tightening on the face and on the body.
The first generation of the Thermage device, the TC3 with an external cooling module, came out in November of 2002, so it’s now been on the market for 12 years. The current third-generation model, the CPT—or Comfort Pulse Technology—has two hand pieces, depending on whether we are treating the face or the body.
When we apply RF to the tissue it produces a special resistance to this electrical current and this generates the heat that produces the collagen shrinkage and new collagen formation. What we get is a two-fold response. First we have an immediate result that we can already see when the patient leaves the office—which is an immediate contraction of the collagen fibres—and then we also have a secondary wound healing response. When we denature the collagen fibres up to 62 degrees centigrade, we get a wound healing and a new collagen deposition that takes place over time. The end result is visible after five to six months, so it’s important that our patients are made aware of this. From a psychological point of view when they leave the office they see a little tightening, but they have not yet achieved the full result.
The CPT system has evolved to include three new key factors. Pulse technology is a pulse delivery of radio frequency—the delivery of five micro impulses of radio frequency each of 200 milliseconds of length, but perceived by the patient as just one pulse. The CPT handpiece has three different levels of vibration, which is a good way to distract the patient from the heat. The tips used to perform the treatment have changed also. They now have a little frame outside and offer a better distribution of the heat throughout the whole surface of the electrodes and also in the depth of the tissue. We get higher temperature levels which are much more comfortable. With the new vibration handpiece the heat stays much longer in the tissue, which is effective because the shrinkage of the collagen fibres is dependent on the temperature and on the time. The CPT has cooling bursts, which occur automatically before we deliver the RF, during this delivery and also after the delivery in order to always protect the epidermis.
A new treatment tip, the total tip, was launched in 2013. These are 3.0 square centimetres. Before this we had several Thermage tips: for the eyes, for the face, and a small and big body tip. Now with the total tip we have a two-fold higher increase of heating in the tissue and therefore better immediate results when the patient leaves the office. This has greatly increased my Thermage business. Before that, when I used the former face tip, I sometimes had the feeling I wasn’t seeing anything and the patient came back after six months and I didn’t see anything then either. But now, since we are heating up more volume of tissue, we’re also getting deeper into the tissue and we see very good results much sooner.
Brain et al published a study in 2010, which showed that the total tip is also safe to use on the face and on the jowls. The protocol is basically the same as before, so the patient is not getting any numbing cream on the skin. I start with a moderate level of energy like 3 to 3.5 and then I’m dependent on patient feedback. So whenever the patient can take the heat, we can go a little bit higher in the energy and if it is too painful we go lower. There is a total of 1200 shots on these tips and I like to give all these shots on one patient in order to get a better result.
Some colleagues of mine in Germany like to split the tip and give only 600 shots to a patient. I think you really need to build up the heat in the tissue in order to get a nice result, so I give a whole 900 shots on the face and if I also do the neck then I give the total 1200 shots. I always ask my patients to rate their pain on a scale between 0 to 4, where 4 is very painful and 0 is no pain. The optimum is around 2.5.
When I start to treat I do two complete passes on the area and then we have to follow our vectors. We have a cheek vector, a jowl vector, a jaw line vector or neck vector that we have to follow with our hand piece at least five times in order to get a nice lifting effect of the forehead, of the cheek and of the neck.
If a patient comes to me with a lot of sagging skin I like to start with one side of the neck, right cheek, right forehead and then I give the patient the mirror to see the nice tightening effect compared to the untreated site.
With Thermage the patient has no downtime at all. You can do it all year round; you can do it in all the Fitzpatrick skin types because it’s independent of your melanin in the epidermis.
With some patients there may be slight redness, but this redness will go away after 30 minutes and then they are ready to wear makeup.
I treated a 68-year-old lady who suffered from breast cancer and was not willing to go under the knife again. She had Glogau IV wrinkles and severe sagging and I wasn’t keen to treat her, but she knew I could offer a non-invasive treatment option. We tried Thermage on her and she got a very nice benefit on the jawline and on the neck. I would have liked to do some fractionated CO2 lasers in order to get these lines also smoother on the cheek but she didn’t want to have any downtime at all.
Combining RF with other treatments
I also like to combine the RF treatments with other treatment modalities like Radiesse volumisers. Since patients don’t see much lifting results at the beginning with RF, I like to give them a little bit of Radiesse in their cheekbones and do the RF treatment right on top. When we finish with the treatment they see an immediate difference and they don’t have to wait five to six months without seeing anything.
To summarise, it’s a perfectly safe combination on all skin types and you can do it all year round. Patients benefit from a single treatment and it’s much less painful then before with superior results. I use the total tip on the face and on the body (arms, thighs) and I use a big body tip 4×4 cm for the abdomen. Using only these two types of tips I can treat a much wider range of patients. Plus, the ones that I would have sent away in earlier times benefit from a good result.
Dr Shirin Sammi-Fard is a dermatologist in private practice in Germany and is the medical director of the Derma Loft. She has worked for 20 years with different laser and light devices. Since 2009 she has also studied energy devices in particular radiofrequency devices.