A Right Old Knees Up

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Fancy a right old knees up? I don’t mean a party with drinking and dancing, however enticing. I mean are you looking to recapture the youthful tautness of the flesh above these oft-unloved joints (“I don’t really like knees,” Yves Saint Laurent once famously quipped). Do you want to summon the firmness you had when you were gyrating to Boy George and Duran Duran, even Donna Summer, on the dance floor? If your knees have started drooping and you’d like to “lift [them] up where [they] belong,” take heart for there is a range of effective non-surgical treatments.

Dr. Mitchel Goldman: “It’s amazing how many people are concerned about knee wrinkles. It’s a big issue, much more so in women than in men, but I’ve had a number of men in their 60s and 70s concerned about wrinkling too.”

San Diego dermatologist, Mitchel Goldman, advocates a comprehensive approach combating slackness from the inside out. For New York City dermatologist, Roy Geronemus, while current treatments are helpful, it is the promise of imminent future technologies that gets him fired up. And for his New York City colleague, Doris Day, improving skin quality takes center stage in knee rejuvenation.

“In the past, there wasn’t much we could do for knees,” says Dr. Goldman.” Plastic surgeons cut, pulled and sewed the skin, but that never worked. “It gave you a horrible looking scar even in the best of hands and the skin would always retract back to where it was.”

Today, Dr. Goldman employs a 3-pronged approach geared to maximize collagen production. First, he injects a biostimulatory agent, then he heats the deeper layers of the skin with either ultrasound or radiofrequency and then he advocates taking a collagen supplement.

Traditionally used to plump and sculpt the face, both Sculptra and Radiesse are biostimulatory dermal fillers which stimulate the body’s natural production of collagen.  For knee treatment, the fillers are diluted to a thin solution before injection. Nor are these fillers restricted to the knee area. They can be used on arms and thighs too. “There are many different areas and they really help the skin to thicken,” explains the dermatologist.

Dr. Goldman is careful to note that none of the available treatments are a “one and done” deal. A successful outcome will require multiple injections and energy treatments. In addition, the aging process requires touch-up maintenance every 2-5 years. “I really try to impress upon my patients that this is going to be a process that’s going to take at least 6 months from the first day of treatment for them to be really happy.”

Next, comes tightening the skin with one of three different devices – Thermage which uses radiofrequeny or Ulthera and Sofwave which use ultrasound. Although the methodologies differ, all use focused energy to heat the dermis, thereby contracting the skin.

“When we use both of these techniques – putting in the biostimulatory filler and adding heat, “we get a way better result,” reveals Dr. Goldman. “We stimulate those cells called fibroblasts to make even more collagen and elastin fibers and we help to really thicken the skin and remove the wrinkles.”

Third in Dr. Goldman’s knee-lifting arsenal is collagen supplements. “The final part of the puzzle is ‘How do we stimulate the body to do things even better than we can with injections and heating technologies?’ And one of the things we’ve come to realize is that ingesting collagen isn’t as hokey as you would think.”

Once dubious about the benefits of such supplements, reasoning that the consumed collagen would be broken down in the stomach before it reached the skin, the dermatologist has since changed his mind.

Momentous collagen powder.

“More and more studies now are showing that if we do a collagen supplement, we can help the body build more collagen under the skin,” he reveals. With a multitude of supplements on the market, many of them “pretty junky” in Dr. Goldman’s opinion, the issue is choosing the right one.

Dr. Roy Geronemus: “Changes are imminent with technologies on the horizon that might provide more benefit than what we’ve seen to date in either non-invasive or relatively non-invasive options.”

At the moment, having looked at the clinical studies, the supplement Dr. Goldman recommends to his patients and takes himself, is Momentous. “You can get away with fairly good results with one [of the above treatments], says Dr. Goldman, “but if someone really wants to achieve a great result and really wants to look 10-20 years younger, you’ve got to do all three.”

For Dr. Geronemus, “there is no holy grail for knee laxity. There’s no magic wand you can wave and the laxity of the knees gets markedly better.” While there are ultrasound and radiofrequency devices “that are helpful for mild laxity, where one can see benefits,” there are several advances which seem especially promising.

The treatment of microneedling with radiofrequency is constantly improving, for example. The Genius device, preferred by Dr. Geronemus for its relative ease of use and greater comfort level for the patient, will be introducing longer, deeper needles better suited to treating the body than the face. “That’s one thing we’re looking forward to,” says Dr. Geronemus.

In addition, some burgeoning therapies seem particularly encouraging. There’s a new concept called micro-coring, an FDA-cleared technology that uses hollow needles to excise tiny columns of dermal and epidermal tissue via a mechanical device called ellacor. As the area heals from these micro-injuries, the skin contracts. “We’ve been doing this on the face and neck and we’ve been seeing some benefits there,” says Dr. Geronemus, “so I would expect over time, use will be expanded to the body, including the knees.”

Cytrellis’s ellacor system relies on micro-coring technology which doesn’t use heat, ultrasound or laser technologies. Instead, it employs controlled removal of thousands of tiny columns of skin via hollow needles, thereby stimulating collagen production.

There’s also an emerging field called Focal Point Laser Technology where the lasers are delivered differently — deeper into the skin, sparing the superficial layer of skin. This is another forward-looking concept that could potentially be used for the knees,” says Dr. Geronemus, “but the data is not there as of yet.”

So how imminent are these treatments? Within six months to a year, according to Dr. Geronemus who cites Genius and Sofwave as his current favorite devices, but “if you ask me six months from now, it could be ellacor and the newer laser technology. What we’re looking for is something that’s consistently better than what we have.”

Dr. Doris Day: “People do care about their knees. They are coming in more and more with questions. It’s an area of concern.”

Dr. Doris Day emphasizes the importance of skin quality as a first step in treatment. To that end, she recommends several topical lotions, beginning with a retinol. “My own body retinol is a good place to start because it helps firm the skin. It also has Vitamin C, hyaluronic acid and a little bit of salicylic acid, so it’s a really beautifying formula that helps with skin firming and gentle exfoliation.”

She also favors Alastin’s TransFORM Body Treatment, which, with its TriHex technology “does help with firming and crepey skin.” “Honestly,” says the dermatologist, “if people [apply these lotions], they often don’t have to do a lot of other things. I always have them do that for a couple of months.”

In terms of treatments, like Dr. Goldman, Dr. Day likes to combine a biostimulatory such as Radiesse in hyperdilute form with Sofwave’s ultrasound technology. “We have been doing it for patients and have been very happy,” says Dr. Day. And sometimes, she will even de-wrinkle the area with a thread lift. “It’s not a go-to procedure,” says Dr. Day, “but it’s one of the ones that I like.”

L. to r.: Doris Day MD Skincare Retinol Body Serum … Alastin’s TransFORM Body Treatmnet with TriHex Technology

And what about prevention? Is there a way of avoiding “kninckles” in the first place? Sun avoidance is the emphatic answer from all three doctors. “The first, second and third point of advice is to stay out of the sun,” says Dr. Geronemus.

“Using sunscreen from an early age really does help in that area,” echoes Dr. Day, adding that diligence with sun protection around joints is especially important because their repetitive motion leads to further breakdown of collagen.

“The single most important thing is to limit sun exposure and use sunscreen because it is the ultraviolet light from the sun and tanning salons that breaks down the collagen and elastin fibers. “That’s what kills the fibroblasts and causes all of the damage,” says Dr. Goldman. “The single most important magic in a bottle is sunscreen.”

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