BBI Contributing Editor

Competing skin rejuvenation technologies are giving both practitioners and patients pause in determining which system offers the greatest overall benefits.

"I think that many systems can work for rejuvenating the skin," said Brian Zelickson, MD, a dermatologist in private group practice in Minneapolis, Minnesota. Zelickson divides current technology into two broad categories. "One type focuses primarily on stimulating collagen, while the other type focuses on removing enlarged blood vessels and irregular pigmentation due to sun damage, along with stimulating collagen."

Zelickson, an assistant professor of dermatology at the University of Minnesota, said he believes choice should be dictated by patient population and anticipated outcomes. Technology geared toward stimulating collagen is generally characterized by longer wavelengths and less melanin absorption. "You're primarily focusing on removing fine lines and wrinkles, and perhaps smoothing out some acne scars," Zelickson noted. On the other hand, the more inclusive technology will treat patients "that not only have fine lines and wrinkles, but also have the other signs of photo-damage, which include enlarged blood vessels or redness of the face, and irregular pigmentation."

Zelickson uses both types of skin rejuvenation systems in his practice. As with many practitioners, "our patients have been our best source of marketing," he said. "Patients refer other patients."

In the spring of 2000, McGhan Medical (Santa Barbara, California) began distributing the Refinity Coblation system (formerly known as Visage). Priced at $19,995, the Refinity uses radio frequency at low temperatures to ablate the epidermis and to transmit thermal damage to the dermis. According to Silvana Kelly, product manager for the Refinity Coblation system, "clinical outcomes have shown that resurfacing with coblation has a rapid healing period." The system uses a temperature of only 70 to 90 degrees C. "It is generally believed that lower temperatures applied to the skin result in a quicker healing cycle," Kelly said. "We also have FDA approval for wrinkle reduction."

Kelly noted that many practitioners feel that non-ablative technology "is not able to reduce wrinkles, although it is an argument that goes back and forth." In fact, she said, "at least one doctor feels that non-ablative equipment has limited capacity to provide much more improvement than a microdermabrasion," she said.

To date, the Refinity system has had more than 100 domestic evaluations by medical specialists, with many of them now regular users.

The co-developer of the single-session Refinity is Roy Grekin, MD, a clinical professor of dermatology at the University of California, San Francisco. Grekin treats one to two patients a week. "We charge the same as for an Erbium YAG or CO2 laser resurfacing. This can range from $500 to $4,5000, depending on the area," he said. Patients with photo-damage and mild to moderate wrinkling are prime candidates. "We've seen very good results," Grekin related. "I'm impressed that the Refinity is easy to use and fast. The postoperative course for the patient is also benign compared to lasers when treatment goes to an equivalent depth." Patients can also return to using make-up within seven to nine days and "the redness fades almost always by a month," he added. Therefore, the Refinity is applicable to male patients who don't like to wear make-up.

"I also like that the Refinity is very compact – about the size of a VCR," Grekin said. Furthermore, "there is no smoke generated as with a laser. And because it is not a light beam, you don't need eye shields for the patient." A disadvantage of the Refinity, however, "is that it takes longer to achieve the results that you are looking for because you don't remove much tissue. You simply damage it, so it can take anywhere from three to six months to see an improvement," he said.

Another hopeful contender is NLite (light-initiated tissue enhancement) technology for skin rejuvenation, which is being distributed by ICN/Medical Alliance (Dallas, Texas). The patented, dye laser-based, non-ablative, wrinkle-reduction technique became available in the U.S. last fall. "The reception for the NLite laser has been excellent," said Beth Emmert, director of marketing. "We launched the product with a training course in 18 cities throughout the U.S. We trained close to 500 plastic surgeons and dermatologists."

Domestically, the NLite laser is available only through a daily rental program. "For a fee, one of our technicians will deliver the laser for a single day," Emmert said. By year-end, nearly all 500 trained physicians had used the laser in their office. "But we are not selling the units at this time. This is how our business model has worked for the past 11 years," Emmert emphasized. The daily rental rate is $1,500. "I know of a Texas doctor who scheduled 18 patients in 1 day for full-face treatment. He charged each patient $1,500."

Emmert said there will be more men willing to undergo the procedure "because there will be no evidence of having had the treatment. There is no damage to the skin. It is noninvasive. There is also absolutely no down-time."

Nita Patel, MD, a dermatologist in private solo practice in Marina Del Rey, California, charges $2,000 to perform a full-face procedure and $500 for segmental areas (periorbital or periaural) with the NLite laser. Patel, who began using the NLite last fall, schedules on average 15 patients a month, all on the same day. "There is no downtime and it is a relatively painless procedure," she said. "We don't even use a topical anesthetic." In addition, the NLite can be used "in any typical office setting that is set up to perform regular laser work. There is no operating room required."

Patel performs all sessions herself and appreciates the fact that the NLite can treat an extensive patient population. "I can treat from 20-year-olds to 80-year-olds," both male and female, she said. "Although most of my patients are women, men don't mind cosmetic procedures that are very gradual and don't require any make-up during the interim healing period." An assistant clinical professor of medicine and dermatology at the University of California, Los Angeles, she said "This procedure is perfect because we're stimulating collagen, which is a gradual process. The results are also gradual." Such a gradual change may be a negative to some patients "because there is not an immediate effect," said Patel, a paid consultant to ICN/ Medical Alliance. "But many patients prefer a procedure where other people don't realize they are undergoing a cosmetic procedure. It takes about three months to achieve the full effect of treatment. The end result is healthier, youthful-appearing skin."

Clinical trials suggest that the NLite is 80% as effective as CO2 resurfacing, "so there will be the ability to repeat the treatment after three months, with the hope of achieving the same results as with C02," Patel noted. Touch-up treatment every one or two years also is viable.

Lars Isaacson, vice president at CoolTouch (Roseville, California), was excited about the January debut of CoolTouch II, which operates at the same 1320-nm wavelength as the first-generation CoolTouch, but has a larger spot size (10 mm vs. 5 mm). "The new version treats a skin area that is four times larger," Isaacson said. The CoolTouch II retails for $79,000, compared to $60,000 for the older version.

"The CoolTouch II has an additional modality called Thermal Quenching," Isaacson said. "This does not replace the original CoolTouch cooling, but it is an option. You can use either pre-cooling, which is the classic method, or you can use Thermal Quenching, which involves firing the laser first and then an immediate pulse of cooling second." In contrast to pre-cooling, which achieves peak temperature deeper in the dermis, Thermal Quenching transfers that peak temperature into the papillary dermis. In short, "classic CoolTouch allows for a deeper treatment, while Thermal Quenching offers a more superficial treatment," Isaacson said. An upgrade to Thermal Quenching is available to current CoolTouch users for an installation fee only. Isaacson said that several hundred CoolTouch systems have been sold over the past 2-1/2 years, with an average domestic price between $65,000 and $69,000.

Mitchel Goldman, MD, medical director of the Laser and Skin Surgery Center of LaJolla (LaJolla, California), has been using the CoolTouch for the past two years. He averages five patients a day and charges $250 to $500 per treatment, depending on treatment area. Three to five sessions are common. "I like the fact that there is no downtime," said Goldman, also an associate clinical professor of dermatology at the University of California, San Diego. "There is also minimal pain, if any." His patient base is "Anyone with wrinkles that has money and desires treatment." The procedure is so popular that "we don't need to do any marketing," Goldman said.

Candela (Wayland, Massachusetts) has launched a new diode-based device called the SmoothBEAM. "Our aim is to create a thermal injury in the upper layers of the dermis, thus causing collagen heating and regeneration," said Paul Cardarelli, director of marketing. "This is a noninvasive method of skin toning," he noted. "Patients who enrolled in a skin-maintenance program in the past might have been subjected to aggressive, ablative treatments. SmoothBEAM enables physicians to offer their patients a fast, noninvasive treatment that can be performed without patient downtime or recovery process." The SmoothBEAM also incorporates Candela's proprietary dynamic cooling device.

Finally, ESC Sharplan (Norwood, Massachusetts) has found a receptive market for its intense pulsed light (IPL) technology for photorejuvenation. Launched last August, the IPL Quantum SR (skin rejuvenation) costs $74,900. IPL technology for photorejuvenation comprises five key properties: effective treatment for rosacea and vascular redness, effective treatment of brown pigment and age spots, effective skin smoothing, treatment of the full face, and a "no-downtime" procedure. "Other technologies currently available can only address some of these properties," said Robert Levenson, global marketing manager for skin rejuvenation. "We've had an excellent reception, both in the U.S. and abroad." Domestic sales represent about 50% of overall sales. "We also now have a simple software upgrade that permits skin rejuvenation users to perform hair removal as well," Levenson said.

Neil Sadick, MD, a dermatologist in private practice in New York, has been using the IPL Quantum SR system since last fall. "For skin rejuvenation, we usually do a series of five treatments, mostly in three to four-week intervals," he said. A single treatment costs $500. Primarily, patients are treated for photo-aging and for redness, including rosacea, pigmentation post-pregnancy and post-inflammatory hyperpigmentation.

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