Skin Firming NuEra Series

Think of lasers as a superficial polishing treatment. Fractional lasers such as Fraxel & pico lasers are best as a ‘cut and polish’ treatment, meaning they help improve the top layers of skin, more so than the lower layers. Lasers are best for superficial & fine lines/wrinkles as well as pigmentation.

RF on the other hand is best for firming, skin tightening & lifting. Slow heating of the lower layers of skin tightens collagen over time. Patients who exhibit both textural changes (such as sun damage & pigment) & skin laxity may benefit from both laser resurfacing & RF skin tightening.

A deep plane facelift (or even a short scar facelift) provides much better traction & lifting. Surgical treatments are still the gold standard in lifting, however they are associated with long down times, surgical risks & costs. Non-surgical options are most effective for cases of mild to moderate laxity, in patients with realistic expectations.

Microneedling is an entry level treatment that is useful for mild cases of scarring, textural changes, enlarged pores as well as fine lines. Though we do perform microneedling at Cutis Dermatology, treatments such as lasers, HIFU, & RF skin tightening are infinitely better at addressing aging concerns such as laxity & loss of firmness.

NuEra is infinitely better than BBL Forever Young. How do we know? We tried BBL for many years (in fact we perform BBL using the Sciton device, but only for pigmentation). BBL is excellent for photodamage & pigmentation, however it does not have the required depth of penetration required to contract & stimulate deep dermal collagen.

Whilst RFM or radiofrequency microneedling with devices such as Morpheus8, Infini, Potenza, Secret RFM, Profound RF & Genius RF are useful for skin tightening, slow heat NuEra RF generally provides better results over time. 

RF microneedling provides fast heating, namely pulses of energy that are less than half a second in different layers of skin. Though we employ these devices to help rejuvenate skin, multiple sessions of slow heat radiofrequency (NuEra), are more comfortable, effective & cost effective for patients.

*Fast heat RF devices such as Morpheus8 are best used with laser resurfacing in the one session. Lasers treat the upper layers of skin, whilst RF microneedling addresses the lower layers. For patients with skin laxity & textural changes, we may combine these treatments. Your treating clinician will discuss the pros & cons of RFM during your consultation.

3 simple steps can optimize your treatments & results. 

1. Use sunscreen & antioxidants. A simple routine consists of antioxidants to prevent collagen breakdown. These include vitamin C, E, ferulic acid & silymarin. Sunscreen? Use an SPF 50+ twice a day, 
2. Eat healthy. A diet high in antioxidants will not only reduce photoaging, but improve your overall health. Collagen supplements are controversial. They do more for your joints than skin, however given the cost effectiveness of supplements, go for it.
3. Smoking kills your collagen production. It’s true. We’re not here to lecture you on the health risks of smoking, however cutting your cigarettes to less than 5 a day will help your skin’s circulation, in turn optimizing collagen production.

At Cutis Dermatology we use different types of collagen stimulating / skin firming injectables to help increase collagen content in the lower areas of skin. These include-

• High & low weight hyaluronic acid
• Poly-l-lactic acids
• Calcium hydroxyapatite collagen stimulating injectables
• Poly caprolactone injectables

Yes & no. It is not hard to get a good result with lifting or anchoring threads, the question is how long they last. Our dermatologists have been performing threads for the past 12 years & here are our thoughts-

• Best & most predictable threads; Silhouette followed by Mint fixing threads
• Second best results; cog threads followed by treatment PDO threads (large bore).
• Poor results; Mint mono PDO threads (unless combined with other treatment modalities). 
• Average longevity of threads (suspension, lifting, fixing); 2-4 months. It is a lot of money to pay for a short duration of action. 

*If you have your mind set on threads because of your research, our dermatologists can perform various threads at your request. Threads are useful, only if combined with other treatment modalities within different levels.

Whilst some skin care products can marginally increase dermal collagen production, they are best used as prevention. Topicals that are commonly prescribed by dermatologists include-

Retinol or retinoids; are the most commonly used ‘collagen’ stimulators as they address photodamage, pigmentation, very fine lines & wrinkles. Brands include Skinceuticals, Synergie, & Murad.

Hyaluronic acid; is a flexible compound used to plump up skin. Injectables such as Juvederm, Profhilo & Restylane are infinitely better than any HA formulation found in creams. Hyaluronic acid belongs under the skin (injected), not on the skin (creams). 

Tocopherol or vitamin E; the all in one skin firming lotion by Nivea. Though we prescribe vitamin E as part of a skin care regimen (as an antioxidant), it does not firm up skin. Given the cost effectiveness of vitamin E, it may be worthwhile considering a lotion for firming up body skin. Placebo can do wonders.

Skin tightening is one of the most complex algorithms to understand. For effective skin tightening, multiple layers of skin require tightening. Here is quick summary of how to tighten skin effectively (from the top down)-

Epidermis: upper layers have minimal impact in the context of dermal laxity, however cytokine release from the upper layer of skin can have a flow on effect to the deeper dermal layers. Microneedling & pico fractional lasers can help stimulate collagen production via a cascade effect, great in theory, not effective for clinical laxity. 

Papillary or superficial dermal layer: lasers including fractional, ablative lasers can help this layer. This layer can also be reached with medium to deep peels such as TCA and phenol, RF also heats this layer, as can superficial fast heat HIFU devices. 

Reticular dermis: deeper CO2 & erbium lasers can be used. Non-ablative lasers such as Fraxel & Alma Hybrid can work. Not a hard layer to remodel, albeit long recovery times. HIFU & RFM can also be used, however these are ‘fast heat’ devices, best combined with slow heat RF (NuEra, Tempsure, Pelleve). CAH, PLLA, HA & PCL injectables work on this layer, as well as the layer up & below. Slow heat monopolar RF devices are useful in this layer, plus the layers above & below. Threads such as PDO/PLLA/PCA work within this level & below. 

Fat & fibroseptal network; harder to treat. Devices that reach this layer include monopolar RF, bipolar RF (Genius, Morpheus8, RFM, Secret, Potenza) as well as HIFU with Ultherapy & Ultraformer. Fast heat devices can have collateral damage to the fat cells, hence why these treatments are best used off label. 

SMAS & fascial layer; harder to treat with predictability. Devices include monopolar RF & HIFU. SMAS & deep plane face lift address this layer (and layers below). 

Muscles; reposition with deep plane facelift, or stimulated with DMS or EMS technology. Complex non-surgical algorithms, new for 2023-2024. Simulation of key muscles including risorius, zygomaticus major & minor may improve resting tone of facial elevators. Nowhere as predictable as a $40,000 deep plane facelift. 

Retaining ligaments; you can ‘support’ with treatments, however deep plane facelift repositions these key elements in patients with severe skin laxity. Energy devices have little effects on retaining ligaments of the face. 

Periosteum & bone; bone loss is one of the most common causes of laxity- think volumetric decrease over the age of 35. Easily replaced with treatments including CAH, PLLA, PCL & most commonly hyaluronic acid. 

To summarize, skin tightening & firming is complex. Ideally different layers should be addressed depending on relative laxity in each layer. RF monopolar devices such as NuEra provide a good, cost effective solution that can address multiple layers including the superficial, middle, deeper dermal layers, the fibroseptal network of fat, & the facial layers. Other treatments may be indicated based upon the patient’s clinical findings including key factors such as the degree of photodamage, elastosis, relative laxity, volume depletion, ethnicity & important expectations.