I remember being told that there is an optimal skin temperature to reach for skin tightening with Aluma (which I assume is the same for other RF or Nd:Yag modalities (Thermage?)) but I can't remember what that temp. is and what temp. is too high. Can anyone help me? thank you in advance. -jmd

I have heard that you want the temp greater than 42 degrees celsius. This causes the thermal trauma needed for the healing cascade to occur. You want to stay under 45 degrees celsius as this may completely destroy the collagen.

So the short answer is between 42 and 45 degrees celsius.

I agree 100% w/ DermaDoc.

The collagen tightens at 60C. It is usually correct to extrapolate that we need to bring the skin surface temp to around 42-45C. However, this is assumed that the person's baseline temp is around 37-38C. Another way to approach this is to bring the person's temp up by 5 degree C. One more very important aspect of skin tightening is the duration of the heating. It is important to MAINTAIN that therapeutic range (i.e. 42-45C) for around 2 minutes. For example, when I do the face, I section out doing the left face first. I make sure I go back to the SAME treated spot within 1-2 minute time. Having finished that "side", I usually give the patient a mirror to compare the treated half to the untreated one. I usually get a good 70-80% instant noticeable improvement of the jowl and NLF's. This is also a great PR tool. By the way, I just described how i performed a thermage of the face

pmdoc,

Which tips are you using? How many pulses do you usually use on a female full face? I have been doing Thermage for about 6 months and have seen some nice results but I am always looking for ways to improve outcomes.

Have you had any fat necrosis? If you look at Thermages technique they recommend to wait at least 2 minutes between passes. This is suppose to avoid overheating the fat. The new stc tips are much faster.

Are you doing Z passes vectors etc?

LH:
The answer to your answer is a bit complex. I have been doing thermage for 3 years now, from the 1.5cm tip to now the 3.0TC, then STC, to the eye tips and now the new DC tips. I am sorry for not being clear. My posting above was mostly about how to treat primarily the "main areas" of the face where bulk heating is much needed such as the jowls, NLF's, marrionette's lines, and submental (double chin area below the jaws). I have been done more than 2000 cases personally without such problems. "Such problems" occurred with mostly the original 1.0cm tips when the baseline fluency was 50-56 J/cm, too hot for shallow areas such as temporal, forehead and under eyes. Besides, because of the "smaller surface area" of the 1.0 tip, the energy delivered was highly concentrated. In addition, another possible explanation was the smaller the tip the "more untreated gaps" were created, thus there were more of very hot sections intersecting colder untreated sections, this inherently caused the "visible skin shrinkage".
If you look at the face "dynamically", the NLF's and jowls are caused by the gravitational pull of the weight of the face pulling it downward and toward the center (medially). This is why it is the hardest to correct the most superior aspect of the NLF's, think of this as a "torque effect" wherein the anchor point is the superior end (the attachment to the base of the nose). All this explanation means you need to deliver more bulk heating in the more "central" areas and less bulk heating as you go laterally and superiorly. This is also the reason for why you may have noticed that patients tend to complain of more heat and pain along the preauricular, lower jawline, etc areas.
The trick in getting very good outcomes for patients AND at the same time minimizing pain and complications is:
1) Adjusting up (2-3 treatment levels) in areas nearest to the midline, except for those patients with painful superficial facial nerve @ the lip corner, here I treat about 0.5 cm from it while pulling the skin laterally
2) As you go laterally along the face you dial down the fluency
3) Whereever you treat the face, always "direct" the skin on an upward direction.
4) JOWLS: Since it is a more sensitive area but needs more bulk heating, I use the same lower fluency but doing 2 successive passes for every one pass elsewhere. This a 2:1 ratio in frequency
5) Place the return pad on the FOREARM. This is based on the principle of RF, the HIGHER the resistance created, the MORE bulk heating delivered to the tissue. For example, whatever the fluency "tolerated" by your patient when the pad is placed on the back, her/his tolerance would stay the same at the fluency about 3 treatment levels HIGHER when the pad is placed on the forearm.PRECAUTION: the patient will feel more heat there. Sometimes I would switch the pad to the other side at halfway point (Pad on the contralateral side of the treated side. Better results this way)
6) Yes, I do alternating square and diamond pattern.
7) Yes, I do Z vector but my OWN way
8) For a FullFace and Neck on 600 pulse tip, here is the breakdown: 210-220 pulses on each side of face
80-90 forehead and temporal/crow's feet. Also higher fluency on the midline section
80-90 neck
Hope this helps
PS: Even the "thermage physician experts" from the company could never come up with such "objective guidelines". I have been to many of those. The problem with them was they issued so called "guidelines or advices" based on "subjective scale" of 1-4 (highly cultural, emotional and pain threshold dependent) and without clear understanding of the highly dependent nature of fluency and pain threshold based on RESISTANCE in a RF technology.
Tell patient that your goal would be to make the treated area felt like a good sunburn with feeling of skin tightening right after (provided no aneasthesia was given to block sensation).

pmdoc,

Thanks for the input. I have done about 30 cases now and want to tweak my technique. I like what you are saying and it makes since. Where are you located? I would think about coming and watching you do a couple of treaments. I would love to learn more from your experience.

thank you all for replying. This was the information I was looking for.

LH:
I am in Los Angeles. I would be happy to be of more help. Where are you located at?

pmdoc,

I am in the midwest. I do make it to LA now and again. I have some family in the area.

LH:
I will be out for most of December. I will try to get back with you in January 2008 about thermage treatment setup. THanks

pmdoc,

Thanks, look forward to hearing from you.

LH

I have the NXT. Yes, I do use the grids.

LH:
By the way, I want to ask you:
1) Which machine do you have??? THe old TC thermage or the new NXT one?
2) Do you use the "grids" during treatment?

LH:
Let me know when you will be in Los Angeles area.

I will.

Thanks

Hi PMDOC,

We have the new nxt and I must tell you our training was hap hazzard as our reps were replaced. We finally think we have a good trainer and my lead APRN is developing more confidence in our outcome. Could you share your experience with the eye tip. Are you seeing good results with it? And lastly, have you had an opportunity to use the DC tip? I am a little skeptical that we can decrease circumferential girth. We have our first case next week.

Thanks,
Mark

Mark:
I am laughing upon hearing about your "thermage training" or lacl thereof. I am not that surprised.
1) Eye tips: In general they are pretty weakly powered tips. I heard of MD's needing one tip per eye. I have been using the regular tips for the eyes even before the "eye tips" came out. The eye tips are good for fine wrinkles but too weak for the "lid lifting" effect. The eye tips are ideal for fine wrinkle on thin skin. For the "eyelid" lifting effect, you would need to also do few passes with the regular 3.0 tips. A better compromise is to use the 1.5cm lip tips for the eyes; stronger power and you would not need to use more than one tip for both eyes and probably no need of using the regular 3.0cm tip on the eye. One big tip: use the Qtip to stretch skin upward (upper eye) and downward (lower eye). You will be amazed at how much skin buried under there, also you are better at delivering the heat thru a thinner epidermis layer, thus more to the dermal layer. Get to about 67 J/cm on upper lid and 50-63 J/cm on lower lid. CAUTION: If you use the lip tip and at these power, place the return pad on the upper or lower arm. Treat the lower one with a bit less power and passes b/c it is shallower area. Since when it works too well it can result in "lazy eye appearance" wherein the inside mucosa turned outward and downward. It happened to a pt of mine so I know ( she was in the 60's, s/p facelift surgery thus her skin is much thinner than normal and I did not dial down my power). Also don't treat much where the tear trough is since it is already bony and bare there.
2) DC tip: I truly don't believe there is much difference therapeutically between the TC, STC and DC tips. The major difference was that the DC tips have the shortest cooling time between pulses since Thermage found out that the cooling time was unneccesarily long. This is mostly the "bottom line" issue for thermage company to speed up the process to make their products more competitive in the market place. The depth of penetration and its clinical effects are similar. I still use the original TC tips for ALL my procedures. If you see the pioneering works on the bodies by Dr. Barbar in Mexico and others in Thailand, etc, they did them all on the TC tips before all these gimmicky STC and DC were on the market.
3) Circumferential Girth Reduction: It does work. I have a set of before and immediate after photos to show you if you send me your email address. I tell them that they might feel a bit more loose when putting their pants back on right after and I usually get that kind of feedback from the patients.

It is easier for me to show you on a real case.
1) Place the pad on the forearm. Try to get resistance reading around mid 100's or higher
2) Don't use the grids. I hate this b/c it masks the patient skin and keep you from "customize" treatment
3) Draw 2 horizontal lines about 1.5 inch above and below the umbilicus.
4) On a 600 3.0tip, I do about 150-175 on the lower third, 200-225 middle, 100-125 upper and the rest on vector. I do the vector last.
5) If you believe in the fundamental of collagen denaturation of bringing it to 59C and maintaining the treated tissue THERE for at least 2-3 minutes, then you treat each third completely before moving to the next one

A. The lower third: This is the most sensitive portion among the 3's but this is also where it has to be most effective since it is at the bottom, thus the suportive foundation.you could treat about 2 lines thru from side to side. It is most sensitive laterally and inferiorly and less as you move centrally. Try to bring your fluency to around 44-50 J/cm. Get the skin to be red and warm. If the patient starts to feel too much pain then dial down but stay with it until you get to the 150-175 pulses
B. Middle Third: You should be able to do 3 lines from side to side. As you move from lateral to central, dial up the fluency by 1-2 knots for every 2 pulses, e.g. you start on the outermost lateral at 44-50J/cm, do it twice as you aim toward the midline, then dial up to 50-63/67 then do it for the next 2 pulses, then 63-67/73. I find that the "effective tightening fluency" to be minimally 63 or higher.
C: Upper Third: This is probably the least important third. Keep it around 50-63 thruout. If she has lots of skin folds on the mid and lower thirds on standing position, I would do no more than 80-100 here and do even more pulses on the on the other thirds.
D. Vector: A good way to know what you are doing is effective is to ask the patient at this time if their lower third is still feeling warm. Here, you start from the umbilicus (67J/cm) vectoring laterally/superiorly (dial down as needed)(upper part) and laterally inferiorly (lower part)(dial on s needed). Also do the waists, vectoring from lateral to medially just about 2 pulses width and from top to bottom (about 3 levels down to near the iliac crest). TIP: If patient told you that her lower third was no longer even remotely warm before you start the vector portion, then spare about 1/3 of the remaining 100 pulse to redo the lower third at higher fluency together with the vector portion.
Note: 1)If pt is poorly tolerant you need to know this very early so you can premedicate better with pain meds, even IV sedations. Feel for the skin warmth and get to the point of reddish/pinkish coloration. Watch for sign of 'exaggerated pain response' to the same fluency, this is probably your treatment limit
2) Make her wear a body spandex (girdle) for a month at all time except for when sleeping. Make sure it is of smooth/even surface and the upper and lower edges go past the thermage treated area in order to avoid "pressurized creases/folds" caused by the spandex's ribbings.
BTW, where is your practice at?? Good Luck. I hope this helps

Geez pmdoc, where do I send my check?
Thanks for such a detailed answer. My e-mail is rmofv@sbcglobal.net If you send me a quick e-mail I will respond with info about our practice and location. Hell, Ill even talk about profit (such as it is) and revenue. I find its very easy to share info. when locations are not in the same geographical territory, which we are not.

Thanks,
Mark

I have the new settings for CT3 1320 nm laser and there is a temp sensor. At 8 Joules and 41 C, I don't feel pain with the technique. At these settins will there be much tightening? I had already thought of doing the areas of the face that the client wanted tightening twice to increase patient satisfaction.

Generally speaking with the 1320 (we have CT2 and Sciton) if there is no pain there will not be results. Heck, that's probably true for any nonablative laser application though.

SLL:
I don't personally have the CoolLipo but I do know how you can achieve the tightening effect using the device. This is your last step after the lipolysis and liposuction steps.
In general, you need to get the patient's baseline skin surface temperature. Then aim to raise it by 5 Celsius to about the 39-45 range and keep that temp constant for 2-3 minutes. Work a portion at a time then move to the next area. For example, let's say the neck. After the lipolysis and liposuction (if needed), there is much loose skin there. Let's say you portion the treated neck into 2 or 3 parts vertically speaking depending on how big the neck is (right & left or right, middle and left) ( not horizontal since your tightening treating motion would be up and down in a constant N shape pattern)
When you are ready, place the fiber against the skin's underside and start rubbing or stroking against it in a constant and steady N pattern back and forth. For safety reason, have someone keep the infrared temp thermometer to tell you of the 5 C rise then make sure it stays there for 2-3 minutes. CAUTION: do not go over 45C (can lead to tissue necrosis). I might simply dial down the power as soon s it gets to 43C just in case there is a time lag in temp reading. The surface temp range reflects about a 59-65C of the subdermal collagen denaturation range. Also be careful of older or Fitz I people with thinner skin and areas of bony and shallow nature. Good Luck.

Dexter is correct. It is absolutely true that one cannot achieve true collagen tightening effects without measurable pain/discomfort from patients (at least with current technologies). However, since the patient is "sedated" during the treatment, we cannot get such feedbacks

I am in the process of buying lasers. I have looked at the Syneron which I feel is a total joke (don't even get me started on the rep) He was not truthful with us from the start.

Does anyone have any personal experience with Alma SHR or thier Pixel? I would love to hear from you.