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It is well-accepted that combination therapies are hands down the best route to exceptional outcomes. More recently, the non-invasive modalities available for these combinations have changed, raising the ceiling of outcomes and opening doors for many who want neither the knife nor the needle.
A recent offering, plus an emergent platform system, yield what might be the most versatile combination yet for facial applications, using devices with significant scientific support behind them.
Emface® from BTL Aesthetics (Boston, Mass.), plus BTL’s new platform Exion® , which features four distinct applicators, can provide never before seen facial improvement without surgery or injectables, according to dermatologist David Kent, MD, founder of Skin Care Physicians of Georgia (Macon, Ga.). Dr. Kent has been involved with clinical trials of both Emface and Exion technologies.
Together, Emface combined with Exion’s radiofrequency-plus-targeted ultrasound (RF+TUS) applicator may be the quintessential needle-free facial protocol. Termed Revitalize and Revolumize (R&R), this treatment captures both the effect of the combination and evokes the gestalt of rest and relaxation associated with an easy, hasslefree procedure. Total time per session ranges between 30 to 45 minutes. “In my experience, you get remarkable results using a course of Emface alone, which provides visible lifting across the mid- and upper face, which affects the lower face and neck,” Dr. Kent began. “Exion elevates the ceiling of what is possible by adding components to combat facial laxity and improve skin quality. This could literally transform the way we approach the treatment of facial aging.”
J.D. McCoy, NMD, medical director of Contour Medical (Gilbert, Ariz), agreed. “The simple message is that we have this powerful new protocol that changes the paradigm, and it actually delivers. As doctors, we are taught first to do no harm; it is a central tenet of medicine. As a naturopathic physician, and, as far as what my patients are looking for, that means choosing the least invasive possible options.
“As physicians, we have this bias,” Dr. McCoy continued. “It becomes almost normal to put needles in the face. To 95% of the population, the idea of needles in the face is ludicrous. People, in general, do not like needles. The idea of something that is needle-free and truly without downtime or pain is extremely exciting. Suddenly, we have a target audience that is exponentially bigger than the audience that would ever conceivably get an injection.”
“‘Needle-free’ means seeking a natural look without injectables or surgery, avoiding that ‘had work done’ appearance,” said Lesley Clark-Loeser, MD, a dermatologist in Davie, Fla. “What is more natural than energy used noninvasively? This is a multi-layered approach to getting that natural outcome. You are improving the resting tone of muscles, the quality of the connected tissue, and the quality of the skin, thus improving the appearance of aging.
“We want people to look like the best version of themselves in real life and with a face that is active and emotional,” Dr. Clark-Loeser continued. “If the face does not respond naturally to that movement, it is noticeable and unnatural looking. It is not that you cannot or should not use injectables, but rather that you do not have to if you do not want it – or you can use them sparingly, artfully. A maximum effect can be achieved from minimal to no injectables, allowing you to use your armamentarium to its fullest potential, and your expertise to express yourself, while the patient walks away looking their best.”
“Injectables are not going anywhere, but they have been around long enough that we have seen overuse that can create a problem at any age, particularly in the younger crowd that may not need as much correction,” said Paul Jarrod Frank, MD, celebrity cosmetic dermatologist in New York City, N.Y. “People want a lifted and tighter appearance without pain and downtime. There is a definite trend of patients looking for an injectable-free solution who do not need that much and do well with these devices. Older patients benefit differently because while they need more correction, this Emface+Exion combination restores the face in a way that sets the stage for more work if they need it. This is unique in the space.”
“People from all walks of life are eagerly seeking nonsurgical solutions without downtime,” said facial plastic surgeon Yael Halaas, MD (New York City, N.Y.). “There is a growing resistance to using fillers and exogenous materials, and concerns have always been about how long they last. The approach we are taking with the Emface+Exion combination is to harness the body’s natural ability to repair and rejuvenate itself, which appeals to patients. It is what the market has been asking for.”
Emface begins with BTL’s signature Synchronized RF and adds high intensity facial electromagnetic stimulation (HIFES™). While the HIFES component selectively stimulates facial elevator muscles to revitalize facial musculature and subsequent structure, Synchronized RF stimulates collagen and elastin while improving local microcirculation simultaneously. This provides a two-vector approach to combat the physical signs of facial aging without downtime or needles. “Unlike BTL’s Emsculpt Neo device, Emface uses the muscle stimulation with the added synergy of Synchronized RF to tone, more than build, muscle,” Dr. Kent explained. “You get thousands of muscle contractions, but the effect is restoration of muscle tone, thus repositioning the facial structure to what is more youthful and functional. The layers of the face do not age independently; we have skin, subcutaneous fat, muscle, and the facial skeleton with connective tissue. In the past, we would generally target the skin, plump the subcutaneous tissue and lift it, but nothing to effectively address the deeper tissues, such as the muscles and the superficial musculoaponeurotic system (SMAS). With R&R, we can nonsurgically target all the different layers. This is where Exion comes into play.”
Exion is a newcomer to the field and features four distinct and powerful applications in a single platform for treating the face and body. Typically, facial sculpting using the R&R protocol begins with Emface to strengthen and tone facial elevators and improve overlying skin quality. Exion’s RF+TUS applicator is used after to stimulate neocollagenesis and neoelastinogenesis1 , improving skin laxity2 and naturally increasing hyaluronic acid (HA).3-5 Skin hydration and texture are also boosted.6 “It cannot be said enough: The neocollagenesis, neoelastinogenesis, and huge boost in HA are the secret sauce that Exion’s Face applicator provides,” Dr. Kent emphasized.
“Repeated studies, some of which I have taken part in, show these remarkable rises in HA,” Dr. Kent reported. “High patient satisfaction is another hallmark of this protocol. You cannot argue with those numbers on top of the more objective evaluations.” For example, Fritz and colleagues3 treated swine on the side of the abdomen (n=12, 9 RF+TUS, 3 RF only) with four weekly, 30-minute sessions. Enzyme-linked immunoassay (ELISA) testing showed an average HA increase of 80 µg/g in the RF+TUS group, with no significant changes in the RFonly group. In a similar study, Duncan et al.4 treated pigs (n=12) with RF+TUS (n=6) vs. RF+non-targeted US (n=6), showing an HA increase of 224% vs. no significant change in HA levels, respectively.
With a patented combination of monopolar RF and TUS, the Exion Face applicator creates therapeutic thermal and mechanical stress to fibroblasts in the deep reticular dermis, according to Dr. Kent. “This is where the improvement in collagen and elastin, and the skyrocketing HA levels, come from with the R&R protocol,” he said. “It is all about the added TUS going deeper to the fibroblasts and the unheard-of increases in HA, which works wonders for the skin.”
As Diane Duncan, MD, director of Plastic Surgical Associates in Fort Collins, Colo. pointed out, the restoration of skin quality has a visibly powerful effect on the overall result. “One thing you will notice – for example, in aging skin of the neck – is loss of the tone, texture and elasticity that gives skin its youthful glow. Instead, it looks crepey, and when you turn, you see wrinkles. The improved skin quality we see from the increases in HA with Exion has a moistening and brightening effect. Skin appears thicker and more toned so that it does not have as much tendency to fold up as aged skin does.”
“BTL started as medical and moved into the aesthetic,” said Chris Robb, MD, PhD, a dermatologist and co-owner of the Skin & Allergy Center (Nashville, Tenn.). “This explains their unique approach and familiarity with the technologies in play. Emface restores facial structure using RF and electrical stimulation to tone, not bulk, facial muscles to a more youthful-looking state. This methodology is very sound, rebuilding the foundation rather than trying to augment what is on top of a faulty foundation, as we often see with injectables. Then we use Exion RF+TUS to improve what is on top of the muscle and fascia, improving collagen and elastin and boosting HA. The RF+TUS creates a synergistic effect in the tissue with RF heating of collagen, elastin and water, combined with the cavitation effect of ultrasound on collagen and water. You see cheek topography restored as if you placed filler, but without filler, the jawline tightens and wrinkles and jowls fade. Perioral and periocular regions look more naturally youthful.”
“When you think of the facial anatomy in layers, the musculature and fascia encompass the deepest levels, and Emface works on that,” Dr. Frank began. Exion RF+TUS non-invasively builds on the next layers up to the surface, restoring tissue volume and elasticity that manifests as we go through sessions over time. It is great to see the ‘nooks and crannies’ level out as we do this without the need for healing or downtime. What you do from there depends on the individual patient’s needs.”
In short, the R&R’s moniker refers to the unique way Emface and Exion revitalize and revolumize. Dr. Halaas put it this way: “When we think of the aging face, the effects of time and gravity pull everything down. Meanwhile, we lose muscle and muscle tone as we age. Skin quality is reduced by aging and sun damage. Emface restores the facial muscle tone and revitalizes the facial scaffold at the level of muscle and bone, but only in specific ways.
“There are more than 40 facial muscles, and Emface only tones the right ones, improving density and tone,” Dr. Halaas continued. “Exion routinely and dramatically improves smoothness and texture, and Emface toning is basically equal to a few syringes of filler. If you reposition a cushion cover without replacing the filling, the sofa will still look old and tired.”
To Dr. Kent, a massive potential benefit of the R&R protocol, and both Emface and Exion systems individually, is that you can treat younger patients. “With these devices, you can appeal to the younger population and, to varying degrees based on individual need, begin the process much sooner,” he expressed. “That would mean previously unseen graceful physical aging using nonsurgical means, and I cannot even imagine how that would look. Within this short, recent span of time, we have seen the rise of Emface and Exion, giving us a one-two punch for facial treatment that simply did not exist a year ago.” For older patients, a key aspect of R&R contributing greatly to the overall result is the treatment of the neck. “When we are doing aesthetic improvements to facial skin, ignoring the neck is a big mistake because then you look like you have a rejuvenated face and an old neck,” Dr. Clark-Loeser explained. “Exion is safe to use on the neck similarly to how we use it on the face. While you would never see a line of demarcation the way one might if we were using lasers, you do get a natural blending as you improve collagen and elastin production, even along the jawline for some immediate tightening.” On top of the excellent combination results with R&R using Emface+Exion, practitioners can further augment results with procedures using other available facial treatments they offer.
Injectables, especially injectable neurotoxins, have long been an entry point or ‘gateway’ treatment for individuals interested in cosmetic procedures. Many people start with these nonsurgical treatments before considering more invasive options, but the profit margins associated with neurotoxins can be relatively small.
“This is because the cost of the product itself and any associated supplies can account for more than 50% of the total treatment cost,” according to Terri Ross, founder and CEO of Terri Ross Consulting, and founder and co-CEO of the APX Platform (Redondo Beach, Calif.). “Some practices use neurotoxins as a ‘loss leader.’ This means they offer these treatments at a relatively low price, potentially even at a loss, to attract clients and build their client base. The hope is that these clients will return for other, more profitable treatments. Many practices are adopting a holistic approach to maximize profitability and patient satisfaction. This involves creating treatment plans combining multiple modalities that comprehensively address the patient’s aesthetic goals. In addition to injectables, practices are incorporating medical devices, such as those offered by companies like BTL, to enhance the overall treatment experience and outcomes. These devices can complement injectables by making them more efficient or effective.
“Poly-L-lactic acid (PLLA) thread lifting works well with this protocol,” Dr. Halaas said. “Threads work best when there is facial tissue and structure to work with, so the Emface+Exion combination works to this advantage specifically.”
“You can do laser-based pigmentation treatments, intense pulsed light (IPL), or even microneedling on the same day,” Dr. Clark-Loeser added. “You can even use a 1927 Thulium laser and do RF microneedling on top of that. BTL technologies play well with others for sure.”
An excellent adjunct is Exion’s own RF microneedling applicator, according to Dr. Robb. “The unique AI-controlled safety features allow this to go deeper than other devices comfortably. This can bring another dimension to the result.”
According to Dr. McCoy, the R&R protocol raises the baseline for any possible adjunctive therapy. “This has become a foundational facial treatment, meaning everything and anything can build upon it. It is appropriate for the full spectrum of patient demographics. My most elderly patient is 87 years-old and achieved a fabulous result. Male patients do amazingly with it. You see, R&R addresses a core concern that 90% of patients come in with – that they look not just aged, but tired or angry. The R&R protocol gives them that refreshed look, and it is partially because you are just addressing so much with a single treatment. Combine this with other elements of the BTL family or other tools that you have in your toolbox. It truly is a foundational treatment.”
Dr. Duncan echoed that sentiment. “What this protocol does is take your skin back years, not in the limited and superficial way we did with lasers, but with functionally restored facial structure and tissue quality that gives a naturallooking result we can build on with other tools in our armamentarium. The safety, outcomes, lack of downtime, ease of treatment, and overall convenience appeal to patients. And the sooner we can intervene, the more we will be able to help patients maintain their youthful facial appearance.”
“Most of the time patients are really coming to see us as an expert, and they want a plan, next steps, they want to know where the treatment is going to lead,” Dr. McCoy emphasized. “We tell patients that this is a marathon, not a sprint. You are never done because the aging process continues, so we want to manage it in as many ways as we can.”
“This approach allows practices to provide patients with a more complete solution to their aesthetic concerns,” Ms. Ross observed. “Patient satisfaction is a crucial aspect of any cosmetic practice. A holistic approach that delivers better results can lead to higher patient satisfaction and loyalty. The goal is to create a diversified revenue stream by offering a variety of treatments. This can help practices remain financially sustainable and competitive in the industry.”
Another aspect of financial sustainability is return on investment (ROI). Part of ROI is the efficient use of staff time, so a device or treatment becomes more profitable when it can be safely delegated to ancillary staff. “Emface and Exion are absolutely delegable procedures,” Dr. McCoy explained. “The technology is very intelligent in design with built-in safety, which is very important for any procedure I bring into the office. These are both very simple and straightforward procedures to set up and administer. The most important component is patient selection and managing expectations while ensuring no contraindications to treatment. And at the same time, it is an opportunity for those ancillary staff not just to administer the procedure, but also educate the patient about the treatment and the other opportunities within the practice, which they enjoy.”
Another important piece of the puzzle is BTL’s customer support. Starting with the rep who comes into your office, it is exceptional, said Dr. Robb. “These people understand your needs, the business and the technology. This continues at conferences where the growing body of research supporting these developing technologies is shared. The reps do not abandon you when you make the purchase; they stick with you and want you to be successful. Their trainers are outstanding, so you and your staff will be well-versed in how to use the devices safely, and if you need help, they are there.
“Marketing support starts with the company’s direct-to-consumer campaigns throughout the country, using billboards and influencer-based presentations that have impacted my business firsthand,” Dr. Robb continued. “People seeking treatment may find you through their website, and I receive regular emails from prospective patients this way. And, of course, BTL is always adding more down the pipeline – not things that make your device obsolete, but that augment and accentuate what you own.”
Dr. Frank cannot speak highly enough about the business side of BTL. “On top of the great ROI we see with these devices is the support that makes the ROI come to life,” he explained. “Direct-to-consumer marketing is essential because it reaches people that doctors simply cannot and creates recognizable branding. The training and support are superior. BTL’s long history with these technologies puts them firmly at the forefront of aesthetic medicine, with safer and effective non-invasive devices that offer easy-to-sell treatments because they live up to the hype. Patients will always choose less invasive and less hassle, but with BTL devices, they do not have to consider the old trade-off of results versus risk and downtime.”
References:
1. Kent DE. Monopolar radiofrequency and targeted ultrasound induces remodelling of fibrillar collagen and elastin fibers: histological porcine model study. Presented at the American Society for Laser Medicine and Surgery (ASLMS) annual meeting, San Diego, Calif., 27 April 2022.
2. Kent DE, Mueller G. A novel technology combining radiofrequency and targeted ultrasound for improvement in skin laxity: the efficacy and safety evaluation. Presented at the American Society for Laser Medicine and Surgery (ASLMS) annual meeting, Phoenix, Ariz., April 13-16, 2023.
3. Fritz K, Bernardy J, Jarosova R, Kralova N. Radiofrequency and targeted ultrasound have shown to enhance natural hyaluronic acid production: porcine animal study. Presented at the American Society for Laser Medicine and Surgery (ASLMS) annual meeting, San Diego, Calif., 27 April 2022.
4. Duncan D, Bernardy J, Hodkovicova N, Masek J. Increased levels of hyaluronic acid in skin after monopolar radiofrequency and TUS treatment: porcine animal study. Presented at the American Society for Laser Medicine and Surgery (ASLMS) annual meeting, San Diego, Calif., 27 April 2022.
5. Goldberg DJ. A novel technology to boost natural production of hyaluronic acid in the skin tissue: human histology study. Presented at the American Society for Laser Medicine and Surgery (ASLMS) annual meeting, San Diego, Calif., 27 April 2022.
6. Chilukuri S, Boyd CM. The simultaneous application of monopolar radiofrequency and targeted ultrasound for improvement of skin hydration and skin texture. Presented at the American Society for Laser Medicine and Surgery (ASLMS) annual meeting, San Diego, Calif., 27 April 2022
