Creating a multi-modality treatment plan can provide many benefits to patients and practitioners alike. When considering a treatment plan for a patient, it may be helpful to use a combination of treatments to get the best results, rather than attempting to treat an area with one modality. In this article, I will discuss a case where I applied a combination approach to improve signs of ageing.
Patient presentation
A 71-year-old female presented to my clinic wanting to look younger, fresher, improve her skin condition and reduce pigmentation and age spots. She had never had any previous aesthetic treatments. At the initial consultation, I asked the patient what concerned her the most when she looks in the mirror, but also what she likes about her face. I feel it is important to focus on the positives and not just the negatives, as these may be areas I can further enhance should the patient wish to.
Upon examination, I noted that the patient had volume loss in her mid-face giving a flattened and tired appearance, and her skin quality looked dehydrated and dull. She also had pigmentation around her face and neck. The patient was concerned about her deep perioral lines but did not feel concerned about the wrinkles on her upper face and felt happy with this area.
Consultation
During the consultation, we discussed the different treatment options, whilst informing her of the cost and timelines as well as the expected results. When carrying out a consultation and preparing a treatment plan, I discuss the patient’s skin type, including skin quality, and their expectations of what results may be achieved.
In many cases, the expectations may be higher than what we can realistically provide. I approach this by showing before and after images of my previous patients (consent obtained) and also ensure the patient understands that outcomes vary based on the individual.
Patient compliance should be discussed in terms of committing to homecare and the treatment plan. It is also important to discuss risks, potential adverse events and any downtime associated with each treatment so the patient can arrange procedures around their schedule, which will improve compliance with the treatment plan.
Following the consultation, we agreed a multi-modality approach of homecare products, radiofrequency (RF) microneedling, non-ablative fractional laser and dermal filler would be suitable. I wanted to target different aspects of the ageing process, beginning with skin health, followed by stimulating collagen production, then resurfacing the skin and finally creating volume with dermal fillers.
We set a rough timeline of six months to carry out all the treatments, as this duration is needed to leave adequate healing time between each treatment. The patient had a strict budget, so I wanted to create the ideal package to meet her needs and expectations. The patient had no contraindications, she was a non-smoker, on no medications and had no allergies.
Skincare
The patient was given a homecare regime of cosmeceutical skincare from AlumierMD consisting of EverActive C & E + Peptide, Retinol Resurfacing Serum 1.0 and Clear Shield Broad Spectrum SPF 42. The patient had not previously used a regular skincare routine. Using ingredients such as vitamin C and retinol enables patients to achieve better and more consistent results when used in combination with treatments due to their collagen stimulating effects.1
Retinoids are an ideal choice for patients to complement their treatments, with more than 700 published studies showing efficacy in treating ageing skin and improving tone and texture, as well as lines and wrinkles.1-3
Vitamin C is also an essential part of an antiageing routine and is beneficial to use at home in between treatments. Vitamin C is essential for collagen production and required for the cross-linking of collagen fibres and formation of the triple helix structure whilst increasing type I and type III pro-collagen messenger RNA levels in fibroblasts.4,5 Vitamin C also interacts with copper ions at the tyrosine active site which inhibits the production of tyrosinase.6 This interaction helps reduce pigmentation and therefore compliments a treatment plan, targeting ageing.
RF microneedling
Following four weeks of using skincare, I began the in-clinic treatment plan with RF microneedling to address skin laxity. Skin laxity is a common complaint, with 75% of the skin’s dry weight made of collagen.7 As the skin ages, collagen breakdown accelerates whilst production slows, resulting in laxity.8
RF technology uses heat to cause controlled thermal damage to collagen by disrupting its triple helix structure, subsequently causing neocollagenesis.8 The delivery of RF via microneedles introduces thermal energy at various depths in the skin. Following an RF microneedling treatment, a wound healing response is elicited.8 The response consists of three phases: inflammation, proliferation and remodelling/maturation, culminating in an increase in collagen levels and an improvement in skin laxity.9
During the first stage, we see the body’s natural response to trauma which consists of redness, oedema, heat and pain. The blood vessels dilate to allow antibodies, white blood cells, nutrients and growth factors to reach the wound area.9 The stage of proliferation involves the granulation of new tissue. The wound is essentially ‘rebuilt’ and fibroblasts lay down new collagen and glycosaminoglycans.9
Fibronectin and collagen type III are formulated, to which a network of blood vessels develop through a process known as ‘angiogenesis.’9 On completion of the proliferation phase, the wound enters remodelling where collagen type III is replaced by type I.9 This phase can last up to a year, hence why patients can see continuing improvement of their skin after a course of RF microneedling has finished.10
The patient’s face and neck were numbed with topical 4% lidocaine cream for 30 minutes prior to treatment. The procedure can be uncomfortable, so we always recommend a topical lidocaine to ensure comfort.
For this treatment, I used the Endymed Intensif device which uses a treatment tip with 25 non-insulated gold-plated microneedle electrodes. It uses fractionated pulse technology that, together with the non-insulated needles, delivers consistent controlled energy throughout the full depth of the tissue being treated. The depth settings range from 1mm-3.5mm needling with RF levels of one to four depending on the area being treated.
I treated the patient’s face with one pass on the following settings:
Forehead, perioral and periorbital – 1.5mm needle depth, power 2
Cheeks – 2.5mm needle depth, power 4
Neck – 1.5mm needle depth, power 3
Erythema was evident post-treatment and patients should be prepared to expect this. The erythema settles after approximately 24 hours. I applied AlumierMD Recovery Balm and AlumierMD SPF 42 immediately post-procedure. A further session of RF microneedling was carried out four weeks later using the same settings and pre-/post-procedure care. Retinol usage was stopped seven days pre- and post-procedure to ensure minimal sensitivity to the treatment.
Laser resurfacing
Following two sessions of RF microneedling, I waited four weeks and conducted one session of non-ablative fractional laser using ResurFX by Lumenis. I wanted to further target skin laxity but also improve signs of sun damage, fine lines and pigmentation. The concept of fractional injury to the skin is well-established and used for general skin rejuvenation, photodamaged skin, acne scars and stretch marks.11
Compared to traditional ablative lasers, non-ablative fractional laser enables rapid healing with less downtime.12 Non-ablative fractional laser works by causing coagulation columns into the dermis which are replaced by new tissue as the process of regeneration occurs, as is also the case with wound healing following RF microneedling.13
The ResurFX laser is a 1565 nm non-ablative fractional device delivering microbeams of 0.11mm in diameter with an energy up to 70mJ. Using this device, I modified the shape and dimension of the scan, increased the number of microbeams per cm2 from 50 up to 500 microbeams which could be delivered in a non-sequential scan-controlled modality.
The device also has the benefit of continuous cooling for added comfort. I applied topical 4% lidocaine to the patient’s face and neck for 30 minutes before cleansing off prior to treatment. As with RF needIing, ResurFX can be uncomfortable, so topical lidocaine is used. I used the preset for skin rejuvenation with a 12mm square spot size with a density (spot s/cm2) of 50 and an energy level of 15mJ.
As with RF microneedling, erythema and mild swelling was noted immediately post-treatment, with AlumierMD Recovery Balm and Sheer Hydration Mineral SPF 42 applied. The swelling subsides in most patients after a few hours, but they may have some redness for approximately 24 hours post-procedure, which was the case for this patient.
Dermal filler
I waited six weeks following the laser treatment before her review in-clinic to ensure the skin had healed. Her skin laxity had improved, and we had achieved excellent results in reducing pigmentation and age spots. I discussed dermal filler treatment as the next stage in her treatment plan. On discussing her concerns, the patient remained focused on improving her perioral area and adding volume in her lips.
I recommended that dermal filler should be used to replace lost volume in the mid-face too. The patient agreed and the procedure was carried out by my clinical nurse Emma Smart. She used 1ml of Teosyal RHA 4 per cheek using a combination of bolus and cannula techniques. She injected two 0.3ml bolus injections to the periosteum to each medial cheek and layered 0.6ml each side using a cannula. She also used a cannula in the perioral area and 0.3ml of Teosyal RHA 1 to smooth the upper lip lines, before adding some subtle volume to the body of the lip using a needle technique.
Results
A multi-modality treatment plan is recommended for patients, such as this patient, as it treats multiple different issues associated with the ageing process. By combining different treatments, we have been able to target multiple issues to give maximum results.
The patient was delighted with the outcome of the treatment, and as shown in Figure 1&2, we can see an improvement in skin quality. Her pigmentation has reduced, with fine lines and skin laxity also reduced. The patient was advised to continue with her homecare products to keep her skin hydrated and protected. I recommended regular Hydrafacials to keep her skin hydrated and a further RF microneedling or laser treatment twice a year to assist with collagen stimulation.
A combination approach
Overall, this case highlighted how effective a multi-modality approach can be for patients. In this case, I treated each layer of the skin, from skincare to working deep into the dermis with RF microneedling, resurfacing with fractional laser to replacing lost volume with filler. Through this method, I created the ideal outcome whilst remaining within her budget.
