It’s reasonable to say that nonsurgical and minimally invasive options tighten facial and other skin to a degree, but to suggest an outcome that rivals a facelift? That may be a stretch.
Ultrasound, radiofrequency and microneedling skin tightening devices work, according to dermatologist E. Victor Ross, M.D., director of laser and cosmetic dermatology at Scripps Clinic Carmel Valley, San Diego, Calif. So do minimally invasive procedures, such as ThermiTight (Thermi), which involves inserting a cannula to heat subcutaneous tissue. And, better yet, are the skin-tightening effects of CO2 laser resurfacing, according to Dr. Ross, who presented on the topic of skin tightening in August 2017 at the Masters of Aesthetics symposium in San Diego.
“The problem is, they’re nowhere near a surgical facelift,” Dr. Ross says. “If you look at [noninvasive] lifting procedures, they may accomplish (and there’s data to support this) 15 to 30% of what a facelift does.”
Skin tightening, according to Dr. Ross, refers to visible changes in the silhouette of the face, or a dimensional change.
Among the popular options for noninvasive skin tightening are Ultherapy (Ulthera, Merz), an ultrasound technology; the radiofrequency monopolar device Thermage (Valeant Pharmaceuticals); and radiofrequency needles of different configurations, including Infini (Lutronic), Profound (Syneron- Candela), Intensif (Vivace) and Intracell (Jacis).
“These devices heat relatively deeply and noninvasively — meaning that there’s no need for incisions and there is no downtime, in the sense of open wounds or incisions,” Dr. Ross says.
These aren’t likely to be facelift or neck lift alternatives, but rather options for patients who don’t want surgical facelifts or neck lifts, or the downtime associated with surgery, Dr. Ross says.
Combination Treatments Make Happy Patients
Providers who use nonsurgical skin tightening devices should consider combining them with other procedures, to increase patient satisfaction. That’s because noninvasive skin tightening does not show immediate results. Patients often have to wait from a few months to a year to see benefits, according to Dr. Ross.
“It’s rare to do skin tightening… without doing something for the more superficial parts of the skin — like fillers and, possibly, neuromodulators,” he says.
For example, Dr. Ross says he often combines noninvasive skin tightening with use of a pulsed dye laser, intense pulsed light (IPL) or potassium titanyl phosphate (KTP) laser to address redness, at the time of the skin tightening procedure.
“You really want to give patients something right away. If you can give them a little party favor by making a brown spot go away and maybe some Botox or fillers for the face, for example, and they come away already with some improvement, they won’t mind waiting for the skin tightening effect,” he says.
Minimally Invasive Tightening Tips
More invasive skin tightening options include ThermiTight, which requires that providers insert a cannula under the skin. Dr. Ross says he uses ThermiTight to tighten skin on the neck, as well as address loose skin on the backs of arms and other areas.
“Normally, we take a little incision in front of the ear, bilaterally, just under the chin. And we have this radiofrequency cannula probe that goes back and forth, like spokes in a wheel. It heats the skin in a controlled fashion, monitoring temperature internally and externally,” he says.
Other laser and radiofrequency devices that can heat skin from the inside out include PrecisionTX (Cynosure) and BodyTite (Inmode). There are several others as well.
“Those are fundamentally different than the RF needles that go into the skin. The needles go perpendicular to the skin; the [cannula-based heating devices] go parallel to the skin. The cannula based approaches tend to be a bigger procedure. You have to make three incisions to insert the cannula. Patients have to be completely numb, with tumescent anesthesia in the neck. We normally have them mildly sedated. And they need [to wear] a compression garment, often, for four or five days after the procedure,” Dr. Ross says.
Combining procedures isn’t as easy with the minimally invasive options as with the completely noninvasive skin tightening devices, according to Dr. Ross.
“We normally don’t do other things the same day, although we have,” he says. “The problem is when you use tumescent solution, it blanches the skin and makes it harder to see your landmarks.”
The Role of Skin Resurfacing
With fancy technologies taking front and center, it’s easy to forget the role of skin resurfacing in skin tightening.
With the CO2 laser, for example, one can improve not only loose skin, but also fine lines and wrinkles and pigmentary changes, according to Dr. Ross.
“I’ll often use the CO2 laser for skin tightening, which usually is better than other skin tightening devices. But patients have to be willing to stay inside for five to seven days, and that’s a big problem for a lot of people who simply can’t carve out that block of time to recover,” he says. “I try to propose that to patients who have fine lines and sagging, who are able to tolerate the downtime.”
According to Dr. Ross, noninvasive skin tightening options are not only going to deliver the least amount of skin tightening, but they’re also the least predictable.
“And patient selection is very important. You can’t take somebody who has too thin a face or too fat a face. Patients sometimes need more than one treatment. Although, Ultherapy often is a one-time deal. But, the problem with most noninvasive skin tightening interventions is that you might have to wait a long time to see results, and results are often subtle.”
CO2 laser resurfacing offers the fastest visible skin tightening results, he says.
“After the patient heals, you see this tightening and progressive reduction of the wrinkles within two weeks,” Dr. Ross says. “So, if you had to categorize options by speed of response, the CO2 laser would be number one; ThermiTight number two….”
The future hope, according to Dr. Ross, is that noninvasive and minimally invasive options will provide results that are closer to those possible with a facelift and neck lift.
“I think the big problem is that most patients, when they’re 60 or 70 and beyond, have so much loose or excess skin that these procedures are not as helpful as we’d like them to be. The real issue is going to be, should we be treating these patients earlier so they don’t progress to very loose skin?” Dr. Ross says. “Secondly, is there a way somehow to shrink the skin more? Not just a millimeter, but five, six, eight or 10 millimeters? Any new device would have to be more robust at shrinking skin and creating more elastic tissue.”