In Paris, during the early 1830s, a new movement called “la chirurgie radicale” was being developed to help improve the lives of “monsters”—people disfigured by burns, trauma, and tumors—so that their lives could be more normal. Procedures were performed with no anesthesia, and frequently the patient did not survive the operation.
Many of those burn patients had severe skin contractures that were released and corrected by these innovative surgeons who added extra skin in the form of grafts. Even then, thermal energy was recognized as having the ability to remodel skin, even to over-tighten it, without skin excision.
Today, we are finding innovative ways to control this type of energy, and others, to more precisely use it to tighten skin without the need for surgical excision.
This now drives the aesthetic market. Few patients want surgery. They perceive risk, prolonged recovery time, and the possibility of permanent distortion as strong negatives. We as aesthetic practitioners must come up with safe and effective methods of achieving good results with no scars, little down time, and an affordable cost.
Ideally, various types of tissue could be heated to just the right degree in order to cause protein coagulation without total tissue necrosis. Fractional thermal heating is very effective in causing regeneration of the subcutaneous collagen scaffold that disappears over time. Evaluation of scanning electron micrographs has shown that new collagen and vascular ingrowth peaks at 3-4 months after treatment, and persists for about one year. Significant measurable shrinkage of the overlying skin has been confirmed using 3D computerized measurements.
The creation of inflammation in a treatment region can also cause a clinical response. Microneedling alone, without the addition of heat, is surprisingly effective in generating a tissue response. In order for the response to be sustained, both neocollagenesis and neovascularization must take place. A key here is managing the inflammation so that the response is significant, but the down time is minimal.
A new and rapidly growing area of interest is combining microneedling and topical dermaceutical applications. While the actual amount of skin tightening with needling combined with pharmacologic agents is low, the appearance of skin tightening can be dramatic, as improved hydration and a renewed intradermal collagen and vascular structure improves the dermal “collapse” that is noted with aging.
The energy based device type that best improves soft tissue laxity, causing a measurable contraction of overlying skin, currently appears to be radiofrequency. Microfocused ultrasound also works at this level. Both can create new collagen and new blood vessels within the aging soft tissue layer over time. Laser heating tends to be less thermally efficient with currently available devices. Achieving consistent heat in the treatment region without burning the patient can be tricky. Time on tissue is key. Noninvasive devices can be effective as well, but multiple treatment sessions are usually needed in order to obtain a significant result.
Overall shrinkage of the skin envelope in patients with mild to moderate laxity can be significant. The need for an open facelift has become quite rare. Brow lifts cannot be effectively achieved with RF devices as the target is the fatty layer. MFU has had mild to moderate success in this area.
The correction of focal “pockets” of laxity with RF-based minimally invasive devices is a new area of development. Improvement of malar bags, jowling, and perioral laxity has been significant with subcutaneous RF heating. Central submental skin laxity and suprasternal neck laxity not responsive to an open neck lift can be effectively addressed with these devices.
However, platysmal banding is not able to be effectively corrected with EBDs alone. Significant skin excess, or heavy thick neck skin, is also difficult to correct with a scarless approach.
A maximum of 35% contraction of the skin surface area can be aesthetically achieved. If the amount of excess skin that needs correction exceeds this number, excisional techniques should be used.
Improvement of the décolleté, mild to moderate breast ptosis, and mild to moderate upper arm pendulosity can be achieved using scarless techniques.
Fat reduction can be performed at the same time as skin tightening as long as the volume reduction is not overly large. Contraction of the supporting fibroseptal network with the thermal device using a multilevel approach can help re-anchor the subcutaneous layer so pendulosity is improved.
Use of heat mediated skin tightening in the abdomen is limited by the degree of the existing rectus diastasis. While remarkable skin tightening can be achieved in the abdomen, severe striae and extreme skin excess are other limiting factors.
Thigh, knee, and ankle contouring can be safely performed using heat mediated EBDs. In many cases, excisional thigh lifts are no longer necessary.
As with many new treatments, the idea of nonexcisional skin tightening may generate unrealistic expectations in patients who request nonsurgical techniques. While mild to moderate improvement in many patients can be seen, further research and development is needed in order to optimize this exciting new field.