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  Syneron, Inc. (Irvine, Calif.) recently released the eMatrix
radiofrequency (RF) device delivering significant skin rejuve-
nation results. Experts believe that this fractional RF modality,
branded Sublative Rejuvenation™, belongs in a treatment
category of its own. “Ultimately Sublative Rejuvenation is an
RF technology very different from laser fractional rejuvena-
tion,” according to Stephen Bassett, M.D., medical director
of ShapeCYMRU (Swansea, Wales, U.K.). “Scientifically, the
approach seems to be exactly the opposite of what we see
with laser technology because the effect is concentrated in
the dermis and almost skips the epidermis altogether. It is
effective for a much broader range of patients because skin
type is less of an issue.”                                          September/October 2009
continued on page 3                                                       Circulation 20,000
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Sublative Rejuvenation Maximizes
Dermal Impact to Achieve Significant Results
By Kevin A. Wilson, Contributing Editor
   The concept behind fractional tech-           because the bulk of the effect occurs
nologies is simple: a pattern of ener-           beneath the epidermis and at sub-
gy is applied to the skin impacting              ablative levels of heating, with little           “The technology has been
fractions of the dermis, surrounded              disruption occurring on the surface.              termed sublative because
by healthy tissue which helps to speed           This is best for optimal dermal stimula-
the healing process. Fully ablative CO2          tion of neocollagenesis. It’s exactly the         the bulk of the effect
resurfacing achieved great results, but          opposite of what we expect with laser             occurs beneath the epider-
despite its efficacy, the associated risks       treatments. This makes Sublative Re-
and lengthy downtime caused the aes-             juvenation a radically different ap-
                                                                                                   mis and at sub-ablative
thetic community to virtually abandon            proach to skin rejuvenation and with              levels of heating, with little
this treatment.                                  more than 25 years in this field I do             disruption occurring on
                                                 not use terms like ‘radical’ lightly.”
   Since the unveiling of non-ablative                                                             the surface.”
fractional rejuvenation in 2004, the               “Of course there’s nothing wrong
technology has taken the aesthetic com-          with fractional laser treatment,” he
munity by storm. Although risk and               added. “It’s terrific, but there is a limit
downtime were reduced, numerous                  to how aggressive we can be with
treatments were required to obtain               that technology because of the ener-
comparatively modest results and                 gies involved, and its application is
darker skin types were unsuitable for            very skin type dependant.”
treatment. Further developments led
to ablative fractional resurfacing, most            Michael H. Gold, M.D., director of
often utilizing a CO2 or Er:YAG laser.           the Gold Skin Care Center (Nashville,
These modalities offered rejuvenation            Tenn.) agreed; “Post-inflammatory hyper-
results approaching those seen with              pigmentation is a risk with any of these
fully ablative CO2 resurfacing with-             technologies. For a skilled user, that risk
out the disadvantages.                           was dramatically reduced by fractional
                                                 modalities, but it still exists. However,
  Syneron radically shifted the con-             with Sublative Rejuvenation the risk is
cept of fractional resurfacing into a            significantly diminished.”                        Before Tx
new direction by replacing laser
energy with bi-polar RF, according to
David J. Goldberg, M.D., director of                              Michael H. Gold, M.D.
laser research in the department of                               Director
                                                                  Gold Skin Care Center
dermatology at the Mount Sinai School                             Nashville, TN
of Medicine (New York City, N.Y.).
“By and large, the effect of laser
modalities is greatest at the surface,
and less below the skin’s surface. The              Sublative Rejuvenation with eMatrix
technology has been termed sublative             was introduced to the industry in
                                                 October 2008. The Matrix RF appli-
                                                 cator which performs Sublative Re-
                David J. Goldberg, M.D.          juvenation is FDA cleared for derma-
                Director of Laser Research                                                         Eight days after one Sublative Rejuvenation Tx
                Department of Dermatology        tological procedures requiring abla-
                                                                                                   Photos courtesy of Michael H. Gold, M.D.
                Mount Sinai School of Medicine   tion and skin resurfacing. “Syneron’s
                New York City, NY                goal was to develop an ablative frac-
                                                 tional treatment that was not laser or



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                                                          light-based,” explained Amy Forman         Taub explained. “Only 5% of the skin’s
                                                          Taub, M.D., dermatologist and founder      surface is affected by either ablation
                                                          of the SKINQRI research center             or coagulation. The unique pyramid
                                                          (Lincolnshire, Ill.). “Syneron has a lot   shape of this treatment is critical to the
                                                          of experience with bi-polar RF. They       overall effect, which is a deep volu-
                                                          wanted to figure out not only how to       metric sub-surface heating.”
                                                          cause a matrix of fractional ablative
                                                          injury with this technology, but how          According to Moshe Lapidoth, M.D.,
                                                          to vary the parameters so that the         head of the laser unit at Rabin Medical
                                                          modality would exhibit the flexibility     Center in Tel Aviv, Israel, one break-
                                                          necessary to treat multiple indications    through is that treatment with Sublative
                                                          in the future.”                            Rejuvenation is very tolerable with an
                                                                                                     excellent safety profile, even for darker
                                                                                                     skin types. “Because of the shape of
                                                                         Amy Forman Taub, M.D.       the impact treating darker skinned
                                                                         Dermatologist and Founder   patients is not an issue making Sub-
                                                                         SKINQRI
                                                                         Lincolnshire, IL            lative Rejuvenation a suitable treatment
                                                                                                     for our patient population.”


                                                             “As results were noticed we began
                                                          to realize that it isn’t about the abla-                   Moshe Lapidoth, M.D.
                                                          tion,” said Dr. Taub, who is a princi-                     Head of Laser Unit
                                                                                                                     Rabin Medical Center
                                                          pal investigator for U.S. trials with                      Tel Aviv, Israel
                                                          Sublative Rejuvenation. “When we
                                                          began using Sublative Rejuvenation,
                                                          we were amazed at the wrinkle
                                                          reduction and tightening achieved,
     Before Tx                                            because epidermal impact was so               Sublative Rejuvenation holds a lot
                                                          minimal. Dermal impact was much            of promise for a number of reasons;
                                                          greater. Of course you have to go          foremost the possibilities for treating
                                                          through the epidermis to reach the         darker skin types. “This may be Sub-
                                                          dermis, but with traditional ablative      lative Rejuvenation’s most important
                                                          fractional lasers you get a column of      advantage,” noted Dr. Taub. “People
                                                          tissue damage, which is actually more      with darker skin types age differently
                                                          of an inverted cone shape, where the       than those with lighter skin types,
                                                          hole in the epidermis is larger than       they develop volume loss, loss in lax-
                                                          the width of the area affected in the      ity and some dynamic wrinkling,
                                                          dermis. Users of ablative fractional       without the fine surface wrinkling
                                                          resurfacing are often treating sun         associated with aging of Caucasian
                                                          damage but they’re also looking for        faces. It’s more of a folding. Sublative
                                                          wrinkle reduction and tightening.”         Rejuvenation promises real softening
                                                                                                     of even deep lines, resulting in skin
                                                             Sublative Rejuvenation provides         tightening and textural changes that
                                                          much more dermal remodeling and            dark skinned patients cannot expect
     After three Sublative Rejuvenation treatments        tightening than epidermal remodel-         with lasers or light-based modalities
     Photos courtesy of Amy Forman Taub, M.D.             ing, in a completely novel way, Dr.        due to safety constraints. I think this



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technology is also going to help im-           time, but we seem to be at a standstill
prove acne scars in darker skinned             as far as lasers are concerned. Sub-          “The delivered energy
patients because of the constraints of         lative Rejuvenation sidesteps all this
using lasers.”                                 because RF is all about control of the        creates a pyramid shape
                                               current as it relates to impedance, not       in the skin barely impact-
  Successfully treating skin of color          absorption, like lasers. The delivered
has historically been a challenge for          energy creates a pyramid shape in
                                                                                             ing the epidermis, which
Hema Sundaram, M.D., F.A.A.D., a               the skin barely impacting the epider-         is where the pigment is
dermatologist in Rockville, Md. “Eth-          mis, which is where the pigment is            concentrated. Sublative
nically, my practice is very diverse           concentrated. Sublative Rejuvenation
because it’s located in suburban Wash-         almost completely bypasses the tradi-         Rejuvenation almost com-
ington, D.C.,” she said. “My waiting           tional problems we expect to deal             pletely bypasses the tra-
room on any given day looks like the           with for skin of color.”
United Nations, so treating a variety                                                        ditional problems we
of skin types is a special interest of            Dr. Sundaram described how she             expect to deal with for
mine.”                                         used Sublative Rejuvenation success-
                                               fully on a 47 year old woman from
                                                                                             skin of color.”
                                               Africa with skin type V. “She was
               Hema Sundaram, M.D., F.A.A.D.   experiencing drooping of the malar
               Dermatologist
               Rockville, MD
                                               fat pad and formation of jowls, as we
                                               typically see in patients of this ethnic
                                               type. There was also scarring from
                                               acne and chicken pox which was
                                               becoming more apparent with age.
   “With laser or light-based modali-          She had been to several other practi-
ties we had a catch-22 situation,” Dr.         tioners who told her there wasn’t a
Sundaram continued. “On one side               suitable treatment for her.”
you could increase the fluence for
enhanced efficacy, but you’d cause                “We wanted to treat all these indica-
too much collateral damage to the              tions as well as improve the overall tex-
epidermis. This could lead to post-            ture of her skin,” Dr. Sundaram ad-
inflammatory hyperpigmentation which           vised. “Sublative Rejuvenation, cou-                Before Tx
is quite distressing to patients. On the       pled with FotoFacial RF to treat her pig-
other side you could play it safe, by          mentary issues, jump started a process
ultimately under treating the patient,         that will continue for several months
leading to less collateral damage              after treatment, with apparent ongoing
and reduced efficacy. However, the             collagen remodeling. She’s very pleased
patient is left underwhelmed and               with the significant improvement in skin
unsatisfied.”                                  texture and quality, as well as the
                                               reduced appearance of scarring. Given
   According to Dr. Sundaram, “The             her experience, Sublative Rejuvenation
technology has advanced gradually.             was a revelation to her. It is a truly
Our understanding of how and why               advanced modality that belongs in its
things happen has improved. We’ve              own category.”
refined protocols, improved cooling
mechanisms and lengthened pulse                 “Sublative Rejuvenation is a different             After four Sublative Rejuvenation treatments
widths to maximize thermal relaxation          modality than we’re used to,” added Dr.             Photos courtesy of Tess Mauricio, M.D.




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                                                          Taub. “When discussing ablative lasers,         electrode configuration and the control
                                                          we think in terms of light being absorbed       of current, determined by tissue imped-
                                                          by a chromophore, creating a thermal            ance, is what majorly controls depth
                                                          reaction impacting the epidermis, and to        and shape of wounding; therefore,
                                                          some degree the dermis, all in an effort        wound depths and shapes are pre-
                                                          to get heat to where it will stimulate neo-     dictable and static.”
                                                          collagenesis as a secondary effect. With
                                                          Sublative Rejuvenation, we send RF ener-           The treatment protocol is simple
                                                          gy through a tiny ablation in the epider-       and tolerable. “We use a water based
                                                          mis and it spreads out to literally             anesthetic for about 30 minutes, which
                                                          coagulate demarcated portions of the            we then wash off. The skin is cleaned
                                                          dermal tissue. It’s more than simple heat-      and dried with at least 70% alcohol,
                                                          ing, it is more targeted and at a much          preferably 90%. The skin must be ab-
                                                          higher temperature. There is some abla-         solutely dry. This is essential with Sub-
                                                          tion of tissue, and patients see a slough-      lative Rejuvenation because it helps
                                                          ing off or peeling of tiny scabs in the first   to increase and equalize the surface
                                                          few days after treatment, but it’s the          skin impedance and contributes to a
                                                          coagulation effect in the dermis that stim-     precise delivery of energy,” Dr. Taub
                                                          ulates tightening and the subsequent            noted. An immediate response of edema
                                                          neocollagenesis.”                               and erythema changes the impedance
                                                                                                          and the energy transmission characteris-
                                                             Tiny electrodes are arranged in a            tics so you can’t go over an area again
                                                          grid of positive and negative electrode         during the same treatment session.”
                                                          array. “The electricity flows through the
                                                          array, forming a closed circuit, via the           Pain during treatment has been re-
                                                          skin, of bi-polar RF, leaving a pattern of      ported as 0, 1 or 2 on a scale of one to
                                                          ablative wounds on the skin’s surface           four. “Some patients don’t even ask for
                                                          just before penetrating the deeper skin         a break during treatment, it’s that toler-
     Acne scarring before Tx
                                                          zones,” Dr. Taub explained. “This is            able,” Dr. Taub shared. “You’ll never
                                                          very different than the monopolar RF            need anything more than topical anes-
                                                          everyone is used to, which is a single          thetic.” Cold air is not used during treat-
                                                          electrode that effects the tissue via a         ment and since Sublative Rejuvenation
                                                          capacitive coupling. With Sublative             is not laser or light-based, goggles are
                                                          Rejuvenation it’s the control of the cur-       also unnecessary. Treating a whole face
                                                          rent flow in the bi-polar current array         should take 20 minutes or less.
                                                          through dry skin, and into the depper
                                                          tissue that creates the desired effect.           “Afterward we apply an emollient
                                                          Since it’s a closed circuit, the energy         cream on the patient before they
                                                          doesn’t wander. The impedance of the            leave,” Dr. Taub continued. “They might
                                                          skin is what generates the thermal              look a little red or swollen for a couple
                                                          effect and causes coagulation.”                 of hours, but it goes away quickly.
                                                                                                          Occasionally patients feel a heating up
     Acne scarring one month after one Sublative            The bottom line, according to Dr.             – a sort of burning sensation – within
     Rejuvenation Tx                                      Taub, is that dermal impact is much             half an hour after treatment.”
     Photos courtesy of Michael H. Gold, M.D.             greater than epidermal impact. “Unlike
                                                          laser modalities it isn’t simply about the        According to Dr. Taub, the primary
                                                          depth and absorption of energy. The             indication for Sublative Rejuvenation



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technology will be wrinkle reduction             Dr. Taub is currently studying Sub-
leading to tightening, as well as over-       lative Rejuvenation combined with                 “Usually to get this kind of
all rejuvenation, at least in the short-      Matrix IR (Syneron’s fractionated diode
term. “We can even tackle forehead            laser with bi-polar RF) for acne scars.           tightening, you need a
lines, crow’s feet or nasolabial folds,       “We’ve enrolled 20 subjects and a                 very high energy treatment
things you might not effectively treat        high percentage of them have skin
with a laser unless you’re going high-        types IV and V. Less than one-quarter
                                                                                                and considerable laser sur-
ly ablative. “Usually to get this kind        have actually completed the course of             face coverage, which
of tightening, you need a very high           five treatments with three months of fol-         means a lot of downtime.”
energy treatment and considerable             low-up; however, preliminary results
laser surface coverage, which means           have been promising,” she reported.
a lot of downtime,” Dr, Taub stated.          “Most patients feel they are improving
This is significant because the entry         or their spouses and/or co-workers
point into the dermis is very small with      have noticed a difference. Patients will
Sublative Rejuvenation, so downtime           undergo four or five treatments and
is very short.                                those who’ve had a higher number of
                                              treatments are seeing better results.
   “There will also be a market for           We’ve had no complications so far.”
                                                                                                        Before Tx
those afraid of botulinum toxin injec-
tions, laser treatments or those who
don’t like the idea of maintenance,                           Stephen Bassett, M.D.
especially with injections,” Dr. Taub                         Medical Director
                                                              ShapeCYMRU
added. “This is especially true for                           Swansea, Wales, UK
men. Many of my male patients who
seem to be turned off by injectables
or the idea of repetitive treatments
                                                                                                        After three Sublative Rejuvenation treatments
have been open to the concept of                Dr. Bassett has also seen excellent                     Photos courtesy of Serge Dahan, M.D.
Sublative Rejuvenation.”                      results with Sublative Rejuvenation for
                                              resurfacing and treatment of acne
   Dr. Taub feels it is also important to     scarring. “Patients think it’s fabulous.
point out that Sublative Rejuvenation         They find it to be very tolerable. I like
does not provide pigmentary correc-           that it works even on old acne scars
tion. “Sublative Rejuvenation is not a        that have been previously resistant to
laser or light-based modality, so you         therapy. This is a big issue in the U.K.
cannot treat lentigines or pigmenta-          because the quirks of our medical
tion as the surface coverage is so            system have stunted the growth of
small – only 5%. However, what does           acne scar treatment until recently so                     Before Tx
happen – and this is a key difference         there’s a huge market.”
between Sublative Rejuvenation and
laser rejuvenation – is that the skin            Lori Brightman, M.D., of the Laser
quality changes. Every patient describes      and Skin Surgery Center of New York
a smoothing of the skin, a textural           (New York City, N.Y.) has started
change that cannot be observed in             using Sublative Rejuvenation. With a
before and after photography. It’s dif-       single treatment, Dr. Brightman has
ficult to explain and is most likely relat-   observed results. “I have seen some
ed to dermal impact but that is what          good results with off-label treatment of                  After one Sublative Rejuvenation Tx
patients notice most.”                        stretch marks as well, which I didn’t                     Photos courtesy of Stephen Bassett, M.D.




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                                                                            Lori Brightman, M.D.
                                                                            Laser and Skin Surgery Center of
                                                                                                               “In my experience, Sub-
                                                                            New York
                                                                            New York City, NY
                                                                                                               lative Rejuvenation is com-
                                                                                                               parable or even better in
                                                                                                               some cases than non-abla-
        Before Tx                                          expect. Interestingly, I have also noted            tive or ablative fractional
                                                           a reduction in telangiectasia of the
                                                           scars I have treated.”
                                                                                                               laser rejuvenation.”

                                                              As often happens in science, a for-              treatment parameters, adjusted accord-
                                                           tuitous mistake spawned a burgeon-                  ingly to the patient’s condition and tol-
                                                           ing study of Sublative Rejuvenation                 erance.”
                                                           for port-wine stains. “I accidentally
        After two Sublative Rejuvenation treatments        treated only half a scar and during                    “With Sublative Rejuvenation, the
        Photos courtesy of Stephen Bassett, M.D.           recovery we noticed the vessels in the              downtime is as low as is claimed, which
                                                           treated side of the scar were gone.                 is somewhat rare,” Dr. Bassett added.
                                                           There was a clear line of demarca-                  “In terms of what patients experience,
                                                           tion,” Dr. Brightman elaborated. “When              it’s almost none. There’s a difference
                                                           I treated a patient with striae rubra,              between clinical downtime and social
                                                           we saw a similar effect. Now I am fur-              downtime. Clinical downtime may be
                                                           ther exploring this unique finding for              defined by a variety of criteria, but
                                                           other treatment indications.”                       social downtime is simply how long
                                                                                                               patients feel they must stay in after
                                                              Another future application is perio-             treatment, for whatever reason. Redness
                                                           ral lines, although in Dr. Taub’s opin-             may take a day or two to subside, but
                                                           ion, the energy isn’t quite high enough             patients can apply make-up 12 hours
                                                           yet. “When the next generation is cre-              after treatment if they wish. Furthermore,
                                                           ated it might be useful for perioral lines          there isn’t a complicated post-proce-
                                                           because it not only softens lines, it tight-        dure protocol or skincare regimen to
        Acne scarring before Tx                                                                                deal with. Downtime from the patient
                                                           ens the surrounding area.”
                                                                                                               perspective is easily less than half that
                                                             Dr. Lapidoth presented on Sublative               of what they’d experience with a laser
                                                           Rejuvenation at a recent meeting of                 treatment.” I
                                                           the American Society for Laser
                                                           Medicine and Surgery. “Our histolog-
                                                           ical and clinical results with Sublative
                                                           Rejuvenation are very encouraging
                                                           and interesting. In my experience, Sub-
                                                           lative Rejuvenation is comparable or
                                                           even better in some cases than non-
                                                           ablative or ablative fractional laser re-
                                                           juvenation. Superficial damage is min-
                                                           imal, and the effect is greater as you
        Acne scarring one month after one Sublative        reach deeper into the dermis. Downtime
        Rejuvenation Tx
        Photos courtesy of Michael H. Gold, M.D.           is generally low depending on the



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