Facial firming: Accent laser vs. Refirm

Hello Mina, That is a very good question to ask, as there is significant confusion in the industry for both the consumers and also the doctors that are looking to add the right technologies to their practices. And, you are correct on your assessment of which device to use! The quest to tighten and re-firm skin in the past has always been an elusive endeavor... almost the holy grail of cosmetic medicine.

Most treatments were with surgery, but this only took the old, thin, damaged skin and re-draped it tighter on the face. Ideally we want skin to be thicker, have more collagen and elasticity, and avoid any distortion of how the face looks. The target to change is the collagen of the skin.

Collagen resides between 2 - 3 mm below the skin's surface. When the collagen is heated to between 45-60 degrees Celsius, the coiled-triple-helix collagen molecule actually contracts. When this contraction occurs, there are new "intrafibrillar" spaces that open up, "heat shock proteins" are released, and the body responds by creating new collagen fibers. This is a natural healing process that we've triggered to occur. The result is thicker and more elastic skin.

Refirme

The Refirme by Syneron/ELOS which you mentioned utilizes infrared light energy combined with bipolar radiofrequency energy. There are 2 electrodes approximately 1 cm apart with a sapphire crystal in the middle where the infrared energy is transmitted. The electrical energy oscillates between the two electrodes that are 1 cm apart on the skin. On thermal (temperature) evaluation of the Refirme device, it shows that the peak heating in the tissue occurs at 2.5mm depth. This happens to be exactly where the collagen resides.

Therefore, all the energy is directed to the desired target = the collagen. It is important to note that the Refirme Syneron device is FDA approved for skin tightening via wrinkle reduction. This was always the intended target and indication for the device.

Since we started using the Refirme in May 2006 (when it was first approved and released) we have seen 100% success with skin tightening. The very first patient in our practice to receive the treatment (and one of the first in the USA) was my father, at 73 years old, undergoing treatment for leiomyosarcoma (cancer) had excellent results after his first Refirme treatment. You can find his picture on Syneron's website or my own website. (I'll try to upload his pictures on RealSelf if I figure out to do that). There are many, many more pictures available, too.

It is also important to note that the treatment is relatively comfortable, with a minority of patients requesting topical anesthetics. And there is no downtime with the treatment, only a slight edema and pinkness of the skin that resolves quickly.

Accent XL, Thermage, Titan, et al.

On other devices, such as the Accent, or even Thermage, these are monopolar RF devices. One electrode sits on our face, and the other one is a grounding patch on your back. The electrical current goes in your skin, through the collagen, through the fat, nerves, muscles, skeleton, etc until it exits your back. The peak heating is not exactly at the collagen level in these cases. With Thermage, heat profiles have shown it heating the collagen, but it continues to heat even hotter at deeper levels at 5mm or more. This is due to the monopolar nature of the device.

If you look at the FDA MAUDE adverse events database (do search for "Thermage" as manufacturer) it shows 185 adverse events that include scarring, fat loss depressions, nerve damage, etc., which are all related to the excess energy that goes beyond the collagen and also attacks the tissues below it. We consider this unnecessary collateral damage. And all that excess energy results in unnecessary pain that is near intolerable.

Regarding the Accent, it uses a combination of energies, both monopolar and bipolar. We have been watching this since before the FDA approval. The original intended use of the Accent was for body contouring-fat reduction. It was using the energies to target the deeper fat. However, the FDA did NOT approve it for fat reduction, and instead just gave it a skin wrinkles indication instead. So with all the energies being sent through the body, some of it also affects the collagen at 2.5mm.

Another popular skin tightening treatment is called the Titan. This also is not FDA approved for skin tightening or wrinkles. The FDA indication is for tissue heating, muscle aches and pains. Of course doctors can use them "off label."

This device uses only infrared energy to heat the collagen. The temperature profile for this shows the surface of the skin being the hottest, and the temperature drops off by the time it reaches the collagen deeper down. Again, the ideal approach is to actually directly target the collagen, and this is accomplished with the Refirme's bipolar RF combined with infrared.

Refirme is better for skin tightening

So, in summary, to tighten and firm skin, the most direct, safe, and effective way we've seen is with the Refirme treatment. Because of the ability to truly tighten skin and reduce laxity, we have even stopped doing Threadlifts in the office as it still left the skin loose. Costs for the procedure are also significantly less than the Thermage. This is the expected evolution of technologies: over time, it becomes safer, more effective, and less expensive.

Wish you the best! John Shieh, MD