Nonsurgical Skin Tightening: Pyramid to Success

Nonsurgical skin tightening is one of the most frequently searched cosmetic topics today.  The top 5 cosmetic procedures performed in the United States in 2016 were all nonsurgical according to the American Society for Aesthetic Plastic Surgery National Data Bank Aesthetics.  Nonsurgical skin tightening was the 7th most common nonsurgical procedure performed that year.  However, the sheer number of devices and procedures that claim to tighten skin make it extremely difficult for consumers to get an accurate and honest assessment as to where the truth lies.

Over the past quarter century, laser technology, radio frequency devices and ultrasound focused technologies have greatly expanded the options for nonsurgical skin tightening.  Heat is the consistent energy component in nearly all these devices.  Cold devices such as, CoolSculpting and intense pulsed light (IPL) don’t have any effect on tightening.  Chemical peels, particularly ones which penetrate to the mid dermis and beyond are the one exception.  A side benefit of these peels can be skin contraction, but the amount is quite variable.

Thermal energy-based skin tightening devices differ in the amount and speed at which the heat is being applied, as well as, whether it is applied to the skin surface, or beneath the surface.  My first experience with nonsurgical skin tightening was with my use of the ultra pulse Co2 laser for skin resurfacing in the early 1990’s.  Even though these treatments were being done for skin texture enhancements, my patients and I also observed skin contraction.  Richard E. Fitzpatrick et. Al. reported in the dermatology literature up to 43% skin contraction of eyelid skin treated with the ultra-pulse CO2 laser.  Less aggressive nonablative lasers used in fractional resurfacing result in significantly less to no contraction.  For those individuals wanting surface texture improvements, the skin tightening is a bonus.  However, most people today want just skin tightening.  They aren’t willing to put up with the downtime that accompanies laser light energy procedures of any kind.  They also favor noninvasive, or minimally invasive procedures that can be done under local anesthesia or with mild sedation.

External healing devices, a few of which are listed in Table 1 below, apply heat to the surface of the skin for tightening:

Table 1. Surface heating Devices

Thermage

   Ulthera

Titan

    Skintyte II

Pelleve

    Refirme

Thermismooth  

    Exilis

The energy source is either radio frequency or intense focused ultrasound.  In every case, the energy passes through the outer layer of epidermis down to the collagen containing dermis layer.  But in the process heat energy is lost.  Collagen must be heated to 60 degrees Celsius (140 degrees Fahrenheit) for protein denaturation and contraction to occur.  It’s difficult to achieve this temperature by heating the outer skin surface alone.  This is the reason why the amount of tightening with these devices is limited.  Studies suggest skin contraction of only 6-8%.  Attempts to increase the delivered heat either make the procedure too uncomfortable or increase the risk of burn injury. 

When I’m discussing this option with my patients, I am quick to point out the results are often subtle and last between 12-18 months.  We currently offer Ulthera, which is ultrasound based.  I believe the best candidates for surface based heating with this device are younger individuals with healthy skin. One treatment session is all that is required and generally takes 45-60 minutes.   Treatments are tolerable with Tylenol or Ibuprofen.  Side effects are rare, but occasionally patients can have minor bruising.  There is essentially no downtime and patients return to work immediately.  Maximum results are apparent at 3-4 months.

The second type of skin tightening devices heat the skin from below.  With a minimally invasive procedure, a laser or probe is passed under the skin.  Smart Lipo MPX and ThermiRF/ThermiTight are two such devices.  A recent study published in Aesthetic Surgery Journal, demonstrated skin shrinkage and tightening significantly greater with Smart Lipo MPX than traditional liposuction.  Fat lipolysis’ is an added advantage when using either of these two devices.  The disadvantage with these devices is the inability to control the amount of heat when the laser or probe is under the skin.  This was our experience with the Smart Lipo MPX.  Several patients experienced burn injuries as a result of either the temperature being too high or the laser being too close to the skin.  ThermiRF/ThermiTight uses an infrared camera to detect skin temperature, but this also is prone to variability.  The device doesn’t allow the physician to set a desired temperature.  The internal temperature is often suboptimal and fails to achieve tightening.

The FDA recently approved in the United States, BODYtite and FACEtite, which has been studied in Canada and Europe for the past decade.  This minimally invasive device uses bipolar radio frequency energy to heat the top surface of the skin and under surface at the same time.  Energy passes between a small probe under the skin and a transducer on top of the skin.  This device allows the plastic surgeon to set the desired temperature of the probe and transducer, which guarantees adequate heat to cause maximum skin contraction and tightening.  The temperature controls also provide a safety function to minimize the risk of burn injury.  BODYtite and FACEtite combines all of the best qualities of the other skin tightening devices while at the same time giving the plastic surgeon more control and safety.  Studies support up to 40% skin contraction with this device.

BODYtite and FACEtite is a one-time procedure that can be done in most cases under local anesthesia.  There are no incisions, just small pinhole entry sites.  Skin tightening occurs at the time of the procedure, but best results are evident at 3-4 months and continue up to 12 months after the procedure. Being able to precisely control the temperature under the skin allows the plastic surgeon to melt and remove fat cells for improving contouring at the same time.  FACEtite is used to tighten and contour the jawline, jowl area, and neck.  BODYtite can be used on the abdomen, flanks, underarms, breasts, thighs, and knees.  Patients may experience a few days of swelling following the procedure, but can return to work in most cases, the next day.  

The high demand for nonsurgical skin tightening options is driving the development of new and exciting technologies and approaches.  As with any cosmetic procedure, patient selection and the establishment of proper expectations are key predictors of good results and happy outcomes.