Skip to main content

Vivace® Direct – April 4th, 2024

Provider Protocols: Skin Laxity

Contributor: Gilberto Saenz III, MPAS, PA-C. Dermatology / Plastic Surgery Board Certified Physician Assistant at Austin Plastic Surgeon

Gilberto Saenz III is a Board Certified Physician Assistant who specializes in Plastic Surgery and Aesthetic Medicine. Gilberto provides a wide range of services in his practice including facial injectables, non-surgical and minimally invasive body contouring procedures, laser and light therapies, skincare, as well as assisting the surgeons he works with in their many surgical procedures. However, he will tell you that the absolute favorite part of his job is performing Full Facial Rejuvenation for his patients.


Vivace Ultra™ Uniform Radiofrequency Microneedling was introduced in 2023 to follow its incredibly popular and successful predecessor, Vivace® Microneedle RF, affectionately known now as the Vivace® Legacy. The addition of ultrasound technology to the new platform catapulted Aesthetics Biomedical® (the company behind Vivace® Microneedle RF and Vivace Ultra™) ahead of all other RF microneedling devices. 

RF technology has been utilized in many different and innovative applications throughout history. However, for our purposes in aesthetics, it holds the invaluable benefit of addressing skin laxity without having to rely on invasive surgical procedures.

In order to fully appreciate the benefits and efficacy of RF microneedling, it is important to understand what it addresses. Skin laxity has been a long-standing aesthetic concern affecting a vast and diverse patient population. Until recently; however, there were not many options to address this without undergoing a surgical procedure that more often than not required the use of general anesthesia.  

What is skin laxity and where does it come from?

Skin laxity, in its most simplest terms, is defined as loose skin. The cause of skin laxity is ultimately due to the loss or degradation of proteins in the skin known as collagen and elastin. Collagen is one of the most abundant proteins found in the human body, accounting for approximately 30% of the body’s protein. Although there are different types of collagen, the types that affect the skin and skin laxity are Types I and IV. Type I helps provide structure to the skin, bones, ligaments, and tendons. Type IV is also found in the skin and has its own benefits. Elastin is another abundantly found protein in the body that provides the skin with the ability to bounce back to its normal shape when stretched – in other words its elasticity. 

The loss or degradation of these proteins can be due to several factors. These include, but are not limited to, the natural process of aging, diet, genetics, pollution, smoking, stress, hormonal changes, weight loss and the most common cause, ultraviolet light exposure. Within our practice, Austin Plastic Surgeon (APS), the advent of the weight loss revolution has substantially increased the number of patients seen for concerns of skin laxity. It now far supersedes the number of patients we see to address skin laxity for any other reason. At APS we have developed a number of treatment options and protocols utilizing Vivace Ultra™ not only as a standalone treatment, but in combination with other treatment modalities to address this growing number of patients with skin laxity. 

How does Vivace Ultra™ work? 

Vivace Ultra™ combines the use of microneedling with radiofrequency energy. The addition of linear-array ultrasound technology allows for the visualization and precision measurement of the tissue layer being targeted. In essence, the combination of the microtrauma from the needles penetrating into the skin as well as the RF energy permeating through the tissue, sending heat to the dermal layer where collagen and elastin are stimulated and produced. The synergistic effect of these modalities helps stimulate far more collagen and elastin than microneedling alone does. 

Who is the ideal candidate for Vivace Ultra™?

What makes Vivace Ultra™ versatile is that there are so many different achievable benefits that virtually anyone over the age of 18 years old can be considered an ideal candidate. Additionally, RF microneedling is safe for patients of all Fitzpatrick skin types.  

However, there are patients that may not be excellent candidates for this treatment. Some examples include:

  • Patients who have extensive skin laxity from dramatic weight loss changes
  • Patients who are smokers
  • Patients who may have an active skin infection or open wound in the area to be treated
  • Patients on anticoagulants
  • Patients who have tattoos over the area intended to be treated
  • Patients with a weakened immune system
  • Patients with implantable electronic devices (e.g., pacemakers or defibrillators) 
  • Patients with unrealistic expectations

Benefits and Efficacy

Vivace Ultra™ has been proven to show improvement with skin texture and tone, reduce pore size, reduce the appearance of fine lines and wrinkles, improve in pigmentary changes, improve the appearance of scars and acne scars alike, as well as it’s most valued benefit, improvement of skin laxity. 

Before-and-after photos provided by Austin Plastic Surgeon.  Patient had a combination therapy of Aveli plus three (3) Vivace Ultra™ treatments, each spaced six (6) weeks apart.


I think we can all agree that patient safety should always be of paramount importance when performing any aesthetic procedure or surgery; RF microneedling with Vivace Ultra™ is no different. In preparation of a Vivace Ultra™ treatment, universal precautions should always be followed. 

Treatment setup includes a thorough cleanse of the treatment area, followed by an antiseptic prep. Most commonly utilized preps are Chlorhexadine, Isopropyl Alcohol or Hypochlorous Acid. Proper personal protective equipment (PPE) is vital for both patient and provider safety. Post-treatment care includes a subsequent thorough cleanse with sterile saline solution, application of the Aesthetics Biomedical’s Soothe Mask for 5-10 minutes and Boost Serum, followed by a physical sunscreen. 

Although RF microneedling with Vivace Ultra™ is an extremely safe and tolerable treatment, it is not entirely devoid of the risk for potential side effects or adverse events. Because the form of energy used to promote neocollagenesis within the dermis is heat, one potential side effect is a thermal burn. This can occur if the energy settings are too high or if the length of time the needles are in the tissue is excessive. Another potential risk or adverse event is developing a skin infection, this can occur if the proper precautions were not taken to prep the patient in an aseptic manner. Additional adverse events to consider are erythema, swelling, bruising and bleeding; however, these are typically self limiting and for the most part considered to be a well known and accepted part of the post procedure recovery. These risks and side effects can all be easily avoided if the proper precautions and techniques are instituted throughout the entirety of the treatment process. 

Treatment Protocol

Treatment protocols and settings can vary from practice to practice and provider to provider. In my humble opinion, there are multiple effective and invaluable treatment settings that can be utilized to give our patients superior outcomes. I believe it will ultimately come down to the patient’s tolerance to discomfort and the anesthetic modalities provided to the patient. 

At APS, our protocols consist of the application of topical anesthetic cream. We commonly use a combination topical anesthetic cream known as BLT, which stands for Benzocaine, Lidocaine and Tetracaine, concentrations can vary from the compounding pharmacy. It is a very effective topical anesthetic allowing for quick onset of profound topical analgesia. That is followed by the above mentioned preparation prior to commencing treatment. Once the patient is cleansed and aseptically prepped we can then begin our treatment. We also offer our patients the use of ProNox™, which is a fixed FDA cleared blend of 50/50 Nitrous Oxide and Oxygen, if needed. 

Depending on the patient’s tolerance for discomfort, our goal at APS is to try and push the settings in order to get optimal results. Some examples of settings can be seen below. 

Body Part Power Depth 1st Pass Depth 2nd Pass RF Time Energy
Forehead Level 4 1.0mm 0.6mm 500ms 9.00J
Eyelids Level 4 0.8mm 0.6mm 300ms 7.00J
Cheeks/ Chin Level 5 2.0mm 1.6mm 500ms 10.00J
Nose Level 4 1.0mm 0.8mm 400ms 8.00J
Neck Level 4 2.0mm 1.6mm 400ms 8.00J
Buttocks/ Thigh Level 5 4.0mm 400ms 9.00J
Knees/ Elbows Level 4 2.0mm 500ms 9.00J
Arms Level 4 2.0mm 400ms 8.00J

Combination Therapies

There has never been more appropriate conditions to explore combination therapy for skin laxity, than with the inception of the weight loss revolution. When utilized as monotherapy, Vivace Ultra™ can have a profound impact on the appearance of the skin, as well as its texture and tone. However, we have found that when combined with other collagen and elastin inducing treatment modalities, such as the use of biostimulatory fillers, the effects on the skin are not only synergistic, but revolutionary as well. 

When we incorporate the use of a biostimulatory filler such as Scultpra or Hyper Dilute Radiesse with an energy based device such Vivace Ultra™, we can create what Dr. Johnny Franco, Board-Certified Plastic Surgeon and Founder of Austin Plastic Surgeon, likes to refer to as a “structural sandwich”. By stimulating neocollagenesis in the dermis with biostimulatory fillers utilizing a subdermal approach as well as through the surface of skin with Vivace Ultra™, we can prime the dermis to produce an incredible amount of collagen and elastin.

The biostimulatory filler treatments are typically performed in a series of two (2) separate treatments spaced apart by four (4) to six (6) weeks and scheduled in between the series of three (3) Vivace Ultra™ treatments. In essence the schedule looks like this schedule, with one appointment every four (4) to six (6) weeks.

  • Vivace Ultra™
  • Biostimulatory Filler 
  • Vivace Ultra™
  • Biostimulatory Filler
  • Vivace Ultra™

Patient Education

Without question one of the most important aspects of a patient’s experience in your practice is proper education. This starts with the original consultation and ends with post-care instructions. When a patient is not properly educated and informed about even the smallest details regarding his/her procedure this can lead to miscommunications, misunderstandings, misinformation and most importantly loss of trust by the patient for his/her provider. It is not uncommon for patients to have questions or concerns that may arise post treatment, but if properly educated and informed, many stressful situations and endless back-and-forth phone calls can all be avoided.   

It starts with the consultation. From the initial meeting with each patient we become responsible for not only his/her anticipated outcomes, but also for his/her well-being and safety. First impressions can only be made once; if we do not make a good, lasting first impression on our patients, then we risk losing them long before we’ve even had an opportunity to discuss treatment options.  Discussing the treatment, the potential risks, side effects and anticipated outcomes at length and in great detail is what will truly set you up for success. Additionally, providing an opportunity and safe space where the patient can feel comfortable to ask all questions and feel confident in his/her choice of you as their provider is of paramount importance. 

Follow-up and Maintenance

Another key component for a successful outcome and patient experience is ensuring the patient returns for a follow up visit approximately three (3) months after his/her last treatment session in the series. This will allow the patient face time with his/her provider to discuss any questions or concerns they may have about their treatment outcomes as well as an opportunity for “After” photos to be taken. 

In addition, it is important to convey to the patient the results they achieve from their initial treatment series may not provide long-term improvement. Being transparent with the need for maintenance treatments is necessary. 


The world of aesthetic medicine is ever changing. The weight loss revolution has started a new “golden age” for aesthetic providers and plastic surgeons alike. New ideas and treatments are constantly being shared and evolving, allowing for innovative, modern and oftentimes minimally-invasive approaches to help us manage our patient’s aesthetic concerns with superior outcomes. I truly believe we are in a unique position to be able to witness these incredible advances in modern aesthetic medicine. I can’t wait to see what else the future holds for us and our patients.

Website: | Instagram: @pa_gilbertsaenz, @austinplasticsurgeon

Get In Touch

  • This field is for validation purposes and should be left unchanged.