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No one-size-fits-all approach to tissue-tightening devices



While currently available skin-tightening devices provide a low-risk alternative to surgery, achieving uniform outcomes with them can be tricky.

Dr. Catherine M. DiGiorgio laser and cosmetic dermatologist, The Boston Center for Facial Rejuvenation

Dr. Catherine M. DiGiorgio

“There are many devices on the market, but their efficacy is not consistent,” Catherine M. DiGiorgio, MS, MD, said during the virtual annual Masters of Aesthetics Symposium. “The key to maximizing patient satisfaction is patient selection and setting realistic expectations.”

She avoids recommending the use of tissue-tightening devices for patients who require surgical correction and for those who find the idea of minimal improvement unacceptable. “These are not the treatments for them,” she said. “I also find that when a patient uses her fingers to pull her face back and says, ‘I want to look like this,’ this is not the right patient for these devices. They can get a good amount of improvement, but efficacy is not consistent.”

Still, patients favor noninvasive or minimally invasive procedures for skin tightening now more than ever before. “They are not willing to undergo surgical treatments, and they want something with low downtime,” she said.

Dr. DiGiorgio, who practices at the Boston Center for Facial Rejuvenation, began a review of tissue-tightening devices on the market by discussing the role of ablative fractional lasers such as the carbon dioxide 10,600-nm laser and the Erbium:YAG 2,940-nm laser, which carry risks and downtime. “I don’t view these lasers as a tissue-tightening devices, but they are included because they can provide a little bit of tightening,” she said.

The ideal candidate is someone with skin type I-II and mild skin laxity. “These lasers are really good at improving rhytides,” she noted. “The patient needs to be able to tolerate the discomfort and manage the healing process. Sometimes you can get blepharoplastylike results with some patients. This can be combined with vascular lasers and pigment-targeting lasers to improve the overall texture and tone of the skin. Many combine this with a face-lift or a blepharoplasty. You should wait at least 6-8 weeks after a face-lift before performing this procedure. Some plastic surgeons do combine this with blepharoplasty in the same visit.”

A less invasive option for skin tightening is the delivery of radiofrequency energy, which disrupts hydrogen bonds of the collagen triple helix. This occurs in temperatures greater than 60° C and results in collagen contraction and tightening and neocollagenesis. There are several devices available including transcutaneous monopolar radiofrequency (Thermage, TempSure), subsurface thermistor–controlled monopolar radiofrequency (ThermiTight), and fractional microneedling radiofrequency (Profound RF, Genius RF, Vivace, and Secret RF). The transcutaneous monopolar radiofrequency device delivers energy uniformly via a treatment tip that has contact cooling and coupling fluid. Collagen is denatured at 65° C and fibroblasts are stimulated to form new collagen. The healing process provides additional tightening.

“These treatments are noninvasive; there’s no downtime, and there’s mild discomfort,” Dr. DiGiorgio commented. “Treatments can be done around the eyes, on the face and body. When treating around the eyes with these devices you want to use a corneal plastic eye shield. Contraindications include having a pacemaker, defibrillator, or other electronic implantable device.”

In her opinion, the ideal patient for this device has mild skin laxity or is younger and seeking to maintain a youthful appearance. “It’s great for mild upper eyelid laxity and for temporary improvement of cellulite appearance,” she said. “The patient should not require surgical intervention and the patient should also agree to undergo multiple treatment sessions. Just one treatment session is not going to cut it.”

Another device in this class of technology is subsurface thermistor–controlled monopolar radiofrequency, “which is basically a probe that’s inserted into the skin, most commonly in the submental area,” Dr. DiGiorgio said. An external infrared camera monitors the epidermal temperature, which should not exceed 45°C. This results in a controlled deep dermal and subdermal delivery of thermal energy. “It requires light tumescent anesthesia, and it can be combined with liposuction,” she said. “Common side effects include erythema, edema, and bruising, and sometimes contour irregularities or nodules.” In her opinion, the ideal candidate for this device is someone with mild to moderate skin laxity who does not require surgical correction. “You can combine this with liposuction, but you can achieve good results without it,” she said.

The next device in this class of technology that Dr. DiGiorgio discussed is fractional microneedling radiofrequency. Of several such devices on the market, some have adjustable depths up to 4 mm while others have fixed depths. The energy is adjustable, and the tips can be insulated or noninsulated. “Insulated tips make it safer to perform in darker skin types because the proximal portion of the needle is insulated and the epidermis is spared from damage,” she explained. “Some devices are a bit more painful than others. It does require topical anesthesia; some require local injection anesthesia. Patients have erythema for about 24 hours, and treatments are recommended monthly.” In her opinion, the ideal candidate for this device is someone with mild to moderate skin laxity who does not require surgical intervention but who seeks to maintain a youthful appearance. “Patients should understand that multiple treatments will be required to achieve optimal results,” she said. “I find that there is less improvement in older patients. This can be combined with thread lifts, vascular lasers, pigment-targeting lasers, and CO2 lasers.”

The next device for skin tightening that she discussed is microfocused ultrasound (Ultherapy), which delivers millisecond domain pulses at three different depths that are determined by the transducer that you use. It can go as deep as 4.5 mm. “Each pulse delivers a focal zone of coagulation to achieve tissue contraction,” Dr. DiGiorgio said. “There’s an ultrasound-imaging device attached to it to ensure proper skin contact and the delivery of energy at an appropriate depth. Patients can have a little bit of pain and erythema and edema, sometime bruising. Usually there is not much downtime with these treatments.”

A newcomer in this class of technology is SoftWave, an intense ultrasound beam array (IUB), which delivers energy precisely to the middermis at a depth of 1.5 mm. “With each pulse, the hand piece has seven transducers that deliver energy in 3-dimensional cylindrical thermal zones,” Dr. DiGiorgio said. “You get greater than 25% tissue coverage in one treatment, and there is no injury to the epidermis or deeper structures. It has unique vectors that are along the lines of facial wrinkles, so you get tightening along those lines.”

The procedure takes about 30 minutes, there is no downtime, and it causes no pain, she said. Pretreatment, patients receive topical anesthesia. “This device has active skin cooling and has an ultrasound gel,” she added. “It does not have an imaging platform like the microfocused ultrasound does, because the depth is fixed. You get significant wrinkle reduction and decrease in submental fullness with improvement in jawline definition, eyebrow position, fine lines, and texture.” In her opinion, the ideal candidate for this device is a patient in the mid-40s to early 50s with mild to moderate elastosis, fullness, texture irregularities, laxity, rhytids, elastosis, and photoaging.

She reported having no financial disclosures.

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