Sublative Rejuvenation Maximizes Dermal Impact to Achieve Significant Results

October 1, 2009
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Sublative Rejuvenation with eMatrix was introduced to the industry in October 2008. The Matrix RF applicator which performs Sublative Rejuvenation FDA cleared for dermatological procedures requiring ablation and skin resurfacing. “Syneron’s goal was to develop and ablative fractional treatment that was not laser or light-based,” explained Amy Forman Taub, M.D., dermatologist and founder of the SKINQRI research center (Lincolnshire, Illinois, U.S.). “Syneron has a lot of experience with bi-polar RF. They wanted to figure out not only how to cause a matrix of fractional ablative injury with this technology, but how to vary the parameters so that the modality would exhibit the flexibility necessary to treat multiple indications in the future.”

“As results were noticed we began to realize that it isn’t about the ablation,” said Dr. Taub, who is a principal investigator for U.S. trials with Sublative Rejuvenation. “When we began using Sublative Rejuvenation, we were amazed at the wrinkle reduction and tightening achieved, because epidermal impact was so minimal. Dermal impact was much greater. Of course you have to go through the epidermis to each the dermis, but with traditional ablative fractional lasers you get a column of tissue damage, which is actually more of an inverted cone-shape, where the hole in the epidermis is larger than the width of the area affected in the dermis. Users of ablative fractional resurfacing are often treating sun damage but they’re also looking for wrinkle reduction and tightening.”

Sublative Rejuvenation provides much more dermal remodeling and tightening than epidermal remodeling, in a completely novel way, Dr. Taub explained. “Only 5% of the skin’s surface is affected by either ablation or coagulation. The unique pyramid shape of this treatment is critical to the overall effect, which is a deep volumetric sub-surface heating.’…

“Sublative Rejuvenation is a different modality than we’re used to,” added Dr. Taub. “When discussing ablative lasers, we think in terms of light being absorbed by a chromophore, creating a thermal reaction impacting the epidermis, and to some degree the dermis, all in an effort to get heat to where it will stimulate neocollagenesis as a secondary effect. With Sublative Rejuvenation, we send RF energy through a tiny ablation in the epidermis and it spreads out to literally coagulate demarcated portions of the dermal tissue. It’s more than simple heating, it is more targeted and at a much higher temperature. There is some ablation of tissue, and patients see a sloughing off or peeling of tiny scabs in the first few days after treatment, but it’s the coagulation effect in the dermis that stimulates tightening and the subsequent neocollagenesis.”

Tiny electrodes are arranged in a grid of positive and negative electrode array. “The electricity flows through the array, forming a closed circuit via the skin of bi-polar RF, leaving a pattern of ablative wounds on the skin’s surface just before penetrating the deeper skin zones,” Dr. Taub explained. This is a very different than the monopolar RF everyone is used to, which is a single electrode that effects the tissue via a capacitive coupling. With Sublative Rejuvenation it’s the control of currant flow in the bi-polar current array through dry skin, and into the deeper tissue that creates the desired effect. Since it’s a closed circuit, the energy doesn’t wander. The impedance of the skin is what generates the thermal effect and causes coagulation.”

The bottom line, according to Dr. Taub, is that dermal impact is much greater then epidermal impact. “Unlike laser modalities it isn’t simply about the depth and absorption of energy. The electrode configuration and the control of current, determined by tissue impedance, is what majorly controls depth and shape of wounding; therefore, wound depths and shapes are predictable and static.”

The treatment protocol is simple and tolerable. “We used a water based anesthetic for about 30 minutes, which we then wash off. The skin is cleaned and dried with at least 70% alcohol, preferably 90%. The skin must be absolutely dry. This is essential with Sublative rejuvenation because it helps to increase and equalize the surface skin impedance and contributes to a precise delivery of energy,” Dr. Taub noted. An immediate response of edema and erythema changes the impedance and the energy transmission characteristics so you can’t go over an area again during the same treatment session.”

Pain during treatment has been reported as 0, 1 or 2 on a scale of one to four. “Some patients don’t even ask for a break during treatment, it’s that the tolerable,” Dr. Taub shared. “You’ll never need anything more than topical anesthetic.” Cold air is not used during treatment and since Sublative Rejuvenation is not laser or light-based, goggles are also unnecessary. Treating a whole face should take 20 minutes or less.

“Afterward we apply an emollient cream on the patient before they leave,” Dr. Taub continued. “They might look a little red or swollen for a couple hours, but it goes away quickly. Occasionally patients feel a heating up – a sort of burning sensation – within a half hour after treatment.”

According to Dr. Taub, the primary indication for Sublative Rejuvenation technology will be wrinkle reduction leading to tightening, as well as overall rejuvenation, at least in the short-term. “We can even tackle forehead lines, crow’s feet or nasolabial folds, things you might not effectively treat with a laser unless you’re going highly ablative. “Usually to get this kind of tightening, you need a very high energy treatment and considerable laser surface coverage, which means a lot of downtime,” Dr, Taub stated. This is significant because the entry point into the dermis is very small with Sublative Rejuvenation, so downtime is very short.

“There will also be a market of those afraid of botulinum toxin injections, laser treatments or those who don’t like the idea of maintenance, especially with injections,” Dr. Taub added. “This is especially true for men. Many of my male patients who seem to be turned off by injectables or the idea of repetitive treatments have been open to the concept of Sublative Rejuvenation.”

Dr. Taub feels it is also important to point out that Sublative Rejuvenation does not provide pigmentary correction. “Sublative Rejuvenation is not a laser or light-based modality, so you cannot treat lentigines or pigmentation as the surface coverage is so small – only 5%. However, what does happen – and this is a key difference between Sublative Rejuvenation and laser rejuvenation – is that the skin quality changes. Every patient describes a smoothing of the skin, a textural change that cannot be observed in before and after photography. It’s difficult to explain and is most likely related to dermal impact but that is what patients notice most.”

Dr. Taub is currently studying Sublative Rejuvenation combined with Matrix IF (Syneron’s fractional diode laser with bi-polar RF) for acne scars. “We’ve enrolled 20 subjects and a high percentage of them have skin types IV and V. Less than one-quarter have actually completed the course of five treatments with three months of follow-up; however, preliminary results have been promising,” she reported. “Most patients feel they are improving or their spouses and/or co-workers have noticed a difference. Patients will undergo four or five treatments and those who’ve had a higher number of treatments are seeing better results. We’ve had no complications so far."

—THE European Aesthetic