S. Manjula Jegasothy, M.D.

This is part 3 of a 3-part series with Dr. Manjula Jegasothy.

Part 1: Cutting-edge Rejuvenation: Injectables + Energy Devices

Part 2: How I Decide Which Combination Is Best

It’s important for aesthetic physicians to gain experience using these devices in combination with injectables. Start with the lowest possible settings. Don’t necessarily go by manufacturer recommendations, at first. I always start with low settings to treat myself or my staff and treat as many people as possible with varying skin colors, skin types and ages. After that, you can slowly dial up the devices to settings for which you feel comfortable.

Keep Murphy’s law in mind: Anything that can go wrong will go wrong. Avoid performing a first-time procedure on a patient who has an important photoshoot, event, wedding, trip, etc., in the two weeks following the procedure.

And don’t forget to emphasize sun protection. Patients shouldn’t have direct sun exposure lasting longer than 10 minutes for one week after any device or laser procedure.

It’s a myth that RF and ultrasound devices don’t offer dramatic enough results. When used properly in combination with injectables, they result in noticeable natural-looking skin tightening and lifting. The key is in setting the expectation that while fillers and neuromodulators offer noticeable results quickly, energy devices tend to tighten and lift the skin in the weeks and months following treatment. Explain that even though the energy device may not deliver this huge “wow” factor immediately, it will likely enhance results from injectables without creating the unnatural look of high-dose injectables.

The subtle results of long-wavelength devices combined with the more dramatic results of injectables in any given patient will last for years and even decades, creating a more natural look than could be achieved in the weeks and months after injectables alone.

 is founder of the Miami Skin Institute and clinical associate professor of dermatology at the University of Miami Frost Department of Dermatology, Miami, Fla. She has no conflicts of interest to report related to this article.

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“Explain [to patients] that even though the energy device may not deliver this huge ‘wow’ factor immediately, it will likely enhance results from injectables without creating the unnatural look of high-dose injectables.” Dr. Jegasothy, M.D., Miami Skin Institute.


My Advice: Less Is More With Devices

This is part 2 of a 3-part series with Dr. Manjula Jegasothy.

The optimal use of device-injectable combinations depends on the anatomy and muscular etiology of the patient’s laxity.

If the patient is sagging because he/she has muscular-only laxity of the neck, I might treat that patient with Dysport (abobotulinumtoxinA, Galderma). I use Dysport for the neck because it more evenly spreads over a large surface area comparted with competing neuromodulators. If the patient also has a lot of skin and soft tissue laxity, adding Ultherapy treatment is the better option. A combination of Ultherapy and Dysport tends to be my go-to nonsurgical combination for treating the neck when patients are older than 45 years.

To lift sagging jowls along the jawline, I like to inject Dysport along the inferior mandible, then use Ultherapy to lift the skin and soft tissue in the lower face. I also sculpt the cheeks using filler around and deep to the zygoma, and then sculpt underneath it by lifting the skin and soft tissue with Ultherapy.

For the face, tried-and-true Botox (onabotulinumtoxinA, Allergan), Xeomin (incobotulinumtoxinA, Merz) and Jeuveau (prabotulinumtoxinA-xvfs, Evolus) remain good options for lifting the upper face and brows. My new twist is adding Ultherapy or RF.

To treat the eyelids, for example, one should consider whether the patient has thicker or thinner eyelid skin. I like RF to tighten most eyelids, but if the patient has heavy, droopy eyelids and very thick skin, Ultherapy on the eyelids might be the better choice, along with an Ultherapy “brow lift.

For the mid and lower face, filler would likely be the first-line approach for patients who are thin but have laxity. RF is a good option for the patient who has a full face and sagging, which probably isn’t due to volume loss. Ultrasound is a great option for patients who have sagging and a lot of underlying fat and soft tissue.

Although we don’t often use energy devices on the nose, I’ve found that RF effectively tightens pores, and I use it for that indication.

NEXT: My Advice: Less is More With Devices

Dr. Jegasothy explains how she tackles the decision of which combination therapy will result in the best possible outcome for her patients. According to her, it depends on multiple factors. 

How I Decide Which Combination Is Best

Many of our peers consider skin tightening and lifting with injectables alone to be a little old-fashioned.

When used as a combination therapy, however, nonsurgical tightening and lifting with injectables and energy devices is currently trending at cutting-edge aesthetic practices all over the nation.

Just as injectables made a splash in the aesthetic industry in the early 2000s, ultrasound and radiofrequency (RF) devices have been game-changers over the last decade. They’ve advanced the way we practice and, most recently, the combination of injectable strength and energy device longevity have resulted in achieving what I believe are the best nonsurgical facial lifting and tightening results we’ve seen yet.

Injectables are powerful aesthetic practice tools, but they are limited when it comes to lifting or tightening facial skin. In the past, we might have used a filler to literally “tent” the skin in areas such as the cheeks or the corners of the mouth to pull inferiorly sagging skin upward. While fillers and neuromodulators offer a close-to-instant gratification for wrinkle reduction, injecting the face to get a lifting or tightening effect wasn’t ideal. As patients age, they often need higher dosing of neuromodulators and fillers to do the job, which results in their faces looking more and more unnatural.

Today’s RF and ultrasound devices present a new opportunity to achieve a consistently natural-looking nonsurgical lifting and tightening result, as well as enhance and prolong the wrinkle-reducing, volumizing and lifting effects of injectables.

We are fortunate that in the last decade manufacturers have perfected devices that deliver focused beams of longer wavelength energy (i.e., radio and ultrasound) deeper into the skin than before — bypassing the epidermis and going directly to the dermis and beyond. RF delivers energy to the reticular dermis, while ultrasound can deliver thermal energy to the dermal-subcutaneous junction, the subcutaneous fat and even into the fat-muscle junction and superficial muscular fascia.

When used correctly, these devices can tighten and/or lift skin and soft tissue without delivering heat to the skin, which explains their minimal recovery time and ability to treat different skin types.

While I use the Viora Reaction device, there are many good brands in this niche. Ultherapy (Merz) appears to remain the gold standard for lifting sagging soft tissue and muscle, but there are newer aesthetic ultrasound devices on the market that I have not used but show promise.

The subtle results of long-wavelength devices combined with the more dramatic results of injectables can last for years and deliver more natural results than those of injectables alone. 