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Just Laser It Podcast. Transcript from Episode #2

"Just Laser It" Podcast, now on Apple and Spotify

Dr. Minni Saluja: 

So I love the fact that radio frequency, because it's electrical energy and not a wavelength of light, can be used on any skin type, mine included, which I always love devices that I can use on myself.  And you can use it any time of the year. So even when a patient is tan, you can use RF.

Kane Rogers: 

So when you talk about any skin type, give us a little more clarity into that.

Dr. Minni Saluja: 

There are basically six skin types. They're called Fitzpatrick skin types, and type one is essentially very light. Type two is more like you blue eyes, blonde hair and a lighter complexion.  Type three is my darker haired patients, maybe browner eyes, but still quite light skin. I'm a type four as I have Eastern Indian heritage, a then there's five and six, which are darker skin types. Now, certain lasers, because of the fact that they can interact with melanin, cannot be utilized on darker skin types. So typically with skin type four, five, and six, we kind of have to watch what type of energy based device we utilize on our skin.

Kane Rogers: 

So when you talk about radio frequency and that being for all skin types, what comes to my mind is something like radio waves or something. What is radiofrequency? What are you even talking about?

Dr. Minni Saluja: 

So radiofrequency is electrical energy and it oscillates at a very fast rate. For example, monopolar RF that we utilize for bulk heating or bipolar RF with RF microneedling, we're at the 1 to 6 megahertz delivery, which means that it is oscillating the current back and forth about 6 million times per second. And so this energy, is going into the skin and when it comes across tissue resistance, heat is created.  And that heat is what transfers into stimulating elastin and collagen in the skin.

Kane Rogers: 

So you're basically taking radiofrequency energy, creating heat which then heats the skin and that stimulates the elastin collagen that would, benefit you?

Dr. Minni Saluja: 

That's a good way of looking at it. And there's two major types of radio frequency. There's monopolar radio frequency, and there's bipolar radio frequency, so monopolar radio frequency, that's the type of radio frequency that you might have a neutral pad placed on your back. That's basically the grounding pad. And so this type of radio frequency is more of bulk heating type of radio frequency. It's usually continuous motion. The one that we utilize in our practice is Tempsure which actually has a temperature sensing device, a thermister where it can read what temperature setting you're at. So for example, around the eye area, I set it to 43 to 44 degrees Celsius, and the device alerts me when I've achieved that temperature and it won't supersede that temperature. So it's very safe on the skin.

Kane Rogers: 

So you mentioned the eye area and I've, you know, I've, I know other people have come in for big areas like the legs or something like that. So there's small areas, there's big areas. How do you decide?

Dr. Minni Saluja: 

Basically with RF monopolar, if it's a larger spot size, so for example, when we're doing the abdomen or leg area, I might choose a 60 millimeter spot size. And this is simplistic, but you can think about the depth of the penetration as basically half the size of the handpiece. This helps improve the texture of the skin, and sometimes I will also utilize smooth PDO threads, which we'll talk about in a different episode. When I'm around the eyes, there's a wonderful little 10 millimeter spot size that allows me to go around that periocular tissue. And when I say it is a zero downtime procedure, it truly is. You might be a little bit pinkish red for about 15 to 20 minutes and that's it.

Kane Rogers: 

Okay. So a couple of things. So you talked about energy and heat, which makes comes to my mind. Okay. That might hurt. And then you also talked about a grounding pad. So is it dangerous? So could you address those two things?

Dr. Minni Saluja:  

In this case of monopolar RF, we use a four megahertz system. It is very safe to the underlying tissue.  The grounding pad has to be placed securely on the back, prior to any energy being delivered.  The system will not work without the grounding pad on. It's very similar to electrical surgical devices that are used in surgery. Same thing with a grounding pad. In fact, William Bovie was the one that brought electrical surgical devices to our attention. Back in the early 1920s at Harvard when he used it to basically debulk a tissue mass on on a patient's head. In regard to does it hurt or not? It really truly does not hurt. It feels like a hot stone massage that's occurring. In fact, it even plays this little spa-like music to relax you as well. But it's very, very comfortable. It's just an easy procedure to do. So again, Monopolar radio frequency. Now this differs from bipolar radio frequency and the early iterations of bipolar radio frequency were really more superficial type of treatments because it had both of the electrodes in the hand piece, so they're very, very close together, and the depth of penetration was basically half the distance between those two electrodes. And so it'd be very superficial, but...then, the advent of RFMN allowed us to utilize bipolar RF but select the depth. 

Kane Rogers: 

That's a good point. You often hear of just microneedling and then you've also heard of radiofrequency microneedling. What's the difference?

Dr. Minni Saluja: 

I really wish they would've given it a different name because it gets so confusing. Microneedling alone utilizes tiny needles creating little mechanical fracture in the skin, which does stimulate some collagen. It's also a great way to be able to place topical products into the skin because it creates these little pathways. But it does NOT add radio frequency energy, so Radio frequency microneedling utilizes microneedles, so these little tiny electrodes that go into the skin deliver radio frequency energy, and again, you can titrate the energy settings that you place in there, which then creates the heat, this 55 to 60 degrees Celsius heat that stimulates that elastin and collagen in the skin, which is so vital to really rejuvenate the skin.  That is the major difference and very important on delivering greater results.

K

Dr. Minni Saluja: 

That's the key, RFMN delivers heat to the tissue, whereas microneedling alone does not. And so what's so neat about electrical energy in the form of radio frequency is that it doesn't just stop at the dermis. Electrical energy has a way of even going down slightly below that to the fibroseptal tissue, and it can contract that tissue so you get this little bit of a lifting effect that occurs. So that's the wonderful thing again about radiofrequency. Now there are many, many devices out there.

Back in 2015 when we got our first RFMN device. That device basically was stamping off the skin and it was almost like a staple gun. Again, that was the first iteration which we have since sold and replaced with newer devices.

But, the first device only the tip was a conductor, so multiple passes had to be placed and pinpoint bleeding was the norm. 

With our newer devices, we still numb as certain areas can be a little bit pinchy. But now the devices have a very smooth motor, and it also has non insulated needles, which then, the entire needle becomes a conductor.

The devices that we have, both Scarlet and SylfirmX, in our practice, allows for this NA effect to occur (named after the doctor that invented this), where you create a teardrop configuration in the dermis and rides up the electrode into the upper papillary dermis. You are therefore creating an independent coagulation that starts at the distal ends and runs proximally while sparing the epidermis. 

Kane Rogers: 

Okay. So you, you're, you're kind of losing me

Dr. Minni Saluja: 

Okay. Let's backtrack.

Kane Rogers: 

Here's what I heard you say. Tell me if I'm correct or not. So basically, with the NA effect that you can insert the micro needles and, and the Na effect it gives energy to a greater area.

Dr. Minni Saluja: 

Correct. With an insulated needle needle, you might need do multiple passes to get at the three millimeter, the two millimeter, the 1.5 depth etc, the NA effect creates a teardrop configuration that's a little bit elongated that encompasses the tissue. That allows you to, with one pass, get more tissue coverage.

Now there are times we do a couple of passes, but it allows you to just give greater energy to the dermis which correlates to more coagulation, et cetera. So that's what's really important.

SylfirmX is the newer iteration, which has a continuous wave, which all the microneedling RF microneedling devices have for tissue tightening, but it also has a pulsed wave. And that pulse wave allows us to treat things such as melasma, I dare say melasma, because everybody knows that melasma is one of the hardest things to treat.

I always set the expectations with melasma, that I could make this worse, not better with energy based devices.  And what is so important is to pre treat with topicals before even thinking of adding energy with melasma, but the pulse wave does allow me to create some energy and I can treat it alone or in combo with a Pico pulse laser and get some nice results on a select group of patients with melasma.  I wish it was 100% of the time, but it is not.  

Kane Rogers: 

Do you have a typical patient that when you look at, you think you'd be great for a radio frequency micro needling?

Dr. Minni Saluja: 

Anybody is that patient. But the ones that I always look at are the patients where they might have dark, slightly darker skin types and other devices may not be an option for them. RF microneedling helps to improve the tissue in the neck/jowl area, ocular area. Around the eye area, sometimes we get a little bit of fat herniation and RFMN can help. There's also a microneedling device that's a monopolar device called Agnes that can sometimes get into those zones as well. So those are the type of patients, acne scarred patients, really anybody can be. Even upper leg knee laxity, abdominal laity, arm laxity. There's multiple areas where you can treat.

Kane Rogers: 

So this is really, if I'm gonna oversimplify it, this is really helping tighten skin and provide maybe a little bit of a lift.

Dr. Minni Saluja: 

You got it. And then also because it has these tiny openings from the, the needles allowing a  small portal of entry, topicals can have a pathway down to the dermis. We use a lot of exosomes in our practice, which has the growth factors in it. So that's a great place to put the topical on.

Kane Rogers: 

What would a patient expect from a pain threshold? From a downtime perspective?

Dr. Minni Saluja: 

Sure. And how many type of treatments? Well, from a pain threshold, it, we recommend numbing for one hour prior with BLT cream, betacaine, lidocaine, tetracaine and around the eyes, a little pinchy around the periocular area and around the forehead. Upper forehead, over bone could be a little bit pinchy, but otherwise very, very tolerable. The neck is very tolerable.

Patients can expect a little bit of redness for maybe 24, perhaps 36 hours. There'll be some, a little bit of swelling around the eye area, but it's a very fast recovery because again, it's not ablative lasers, it is rf, which the injury is occurring down deep in the dermis and the top layer is still intact.  We do use it a lot with combination therapy, which again will be another episode as well on how we combine to maximize treatments.  

We typically recommend a series of 3 treatments every 4-6 weeks.

Kane Rogers: 

 So I do want to interject here. We do want to make this interactive with you guys. And so if you go to SalujalaserMD that's Dr. Saluja's DM her, ask her questions, give us show ideas. We'll try and incorporate all your feedback into the show because we want to make this your show just as much as ours. And so again, SalujalaserMD, that's her Instagram Wait a minute, what was that?

Dr. Minni Saluja: 

So for our product spotlight category. The product that we're gonna discuss today, and it's actually a category. Is sunscreen which is so very important. We're talking about all these different things that we wanna do to, to help improve our skin, but we need to, we need to protect our investment and we really need to do that with sun protection. So the main important thing about sunscreen is whatever sunscreen you like, I'm gonna like, because that means you're gonna wear it. That's, that's really the, the first thing. But the second thing is there are some nice things to recommend, and one thing is always try to opt for a mineral sunscreen, a physical blocking agent, like a zinc and titanium based sunscreen. Because what that's gonna do is it's gonna take the UV light and it's gonna bounce off of the skin, rather than absorbing the energy as chemical sunblocks do. So my product spotlight. I really like Elta-MD. I think it's a great sunscreen. The Elta-MD Clear is really good with rosacea. Patients over the counter you can get, I really like LaRoche Posay and I really like their mineral sunscreens as well. So any of those two are great. And again, anything that you utilize, sometimes patients will say, I use Supergoop, or I use this or that. Fine, that's perfect because I know you'll wear the sunscreen. So that's kind of my product

Kane Rogers: 

So is the product spotlight, is this gonna be an ongoing thing?

Dr. Minni Saluja: 

I think so, I'll try to do something like that, but I'll try to recommend something that is more medical grade and I'll try to recommend something that we also like at the drugstore.

In summary, today we discussed RF. There's monopolar radio frequency, there's bipolar radio frequency. In the bipolar category is RF microneedling. There's multiple different companies that have an RFMN device. There's Cynosure that has Potenza. There's InMode that has the Morpheus 8, there's Lutronic that has Genius. Cutera has SecretRF, Benev has SylfirmX, AMPS has Scarlet and finally Cartessa has Virtue, and I think they're coming out with a new one as well.  These are just to name a few.

We have selected SylfirmX in our practice as well as the Scarlet to give you the type of results that we want to see you have.

Remember, aging is 

Kane Rogers: 

So thank you for tuning in. Again, rate review and subscribe if you like the episode. And hopefully you'll be listening to us in the next episode

Author
Raminder Saluja, MD

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