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.
The concept of suspending and lifting tissue using suspension threads originated in ancient Egypt, where golden threads were used under the skin to obtain a bit of inflammatory tightening. It is rumored that these gold threads may have been the source of Cleopatra’s beauty.
Late in the 20th century, the use of gold threads resurfaced in Russia, Asia, and Europe. A Russian, Dr. Adamyan, obtained a US patent for a combination gold/polygycol thread combination in 2000, but these were never commercially produced. Sulamanidze, another Russian, pioneered the Aptos thread beginning in 1997. He cut barbs into his own threads before finding a larger scale manufacturer.
Dr. Alcalmo, a surgeon from New Jersey, applied for a US patent in 1956 for the use of barbed threads that might more securely hold sutured tissue together. These were never commercially developed. Dr. Harry Buncke, well known for his microsurgical techniques, developed a “one-way” suture based on sea urchin spine structure, primarily for the purpose of tendon repair and surgical incision closure. He received a patent for this in 1999.
Woffles Wu in Singapore began using Aptos threads, immediately followed by his own version of barbed threads, in 2001. He noted that the threads “cheese-wired” or cut through the soft tissue, and worked on several adaptations to overcome this, including the “X” lift which intertwined the threads. Dr. Nicanor Isse met Dr. Wu and began producing his own threads. After initial success, he noted the lasting value of barbed threads was not strong. He then began working on coned threads, currently marketed under the trade name “Silhouette”.
While the concept of suspension threads is very attractive—subcutaneous placement under local anesthesia with very little down time—each iteration has failed to prove lasting value to the physician and the patient. Three factors contribute to this problem:
Because of the shortcomings of suture based suspension methods, I began in 2009 to research the possibility of using autologous tissue manipulation to create both skin surface area contraction as well as directional molding of superficial soft tissue.
First, the basic cause of “skin” laxity associated with aging needed to be figured out.
Simple histology provided no clues as to the aging process of soft tissue. Therefore I decided to look at soft tissue using the scanning electron microscope. People’s skin and the underlying adherent soft tissue act as a unit; perhaps by causing the soft tissue mass to shrink, the overlying skin would follow.
While loss of bone and muscle certainly contribute to the aged appearance of many body parts, the skin itself should not take the blame for a region that has started looking old or pendulous. Perhaps if the underlying structure could be restored as a framework for the skin to rest upon, the improvement could be achieved in a manner similar to that of collagen suspension threads—without cheese wiring, breakage, or lack of a sustained response. The collagen formation response would need to be fractional, in order to keep the soft tissue soft.
My first case using this concept for breast lifting was performed in conjunction with a breast augmentation. Evaluation of the patient before surgery showed that her nipple-areolae were quite low, with very little normal skin appearing from the front view. The oblique view shows that her lower breast rests upon the epigastric skin. I knew that implant placement alone would be a bad idea, as the ptotic tissue and nipple complex would hang below the base of the implant.
Following injection of standard tumescent fluid, a minimally invasive bipolar radiofrequency device was used to thermally heat the superficial fatty layer of the breast prior to subpectoral implant placement. The patient also had an abdominoplasty. This combination of procedures gave an incredibly good result.
Limitations of the procedure include the lack of ability to correct all degrees of pendulous breasts. Only grades I and II ptosis are able to be improved with this scarless, nonexcisional RF based technique. The quality of existing soft tissue, and the patient’s compliance with wearing postoperative support garments can significantly affect and limit final outcome. While some lifting is apparent immediately, most patients see a peak of improvement at 6-12 months.
How long do these results last? Again, it depends on the individual. Some patients see additional improvement without retreatment for up to 2 years. At four years, a small amount of aging is visible, but the appearance does not return back to the pre-op level of laxity by this point.
New techniques are able to provide directional shaping as well as overall skin envelope reduction. By providing focal tightening in areas that are significantly lax, a defined round breast shape can be created. The challenge of reducing nipple-areola diameter remains; this cannot be corrected with the subcutaneous device alone. Research into deep RF needling may provide additional help in superficial skin contraction.
Radiofrequency energy is being used to tighten skin, as well as to mold and directionally shape masses of soft tissue. The ability to focally correct areas of pendulosity using minimally invasive devices may provide a solution to problems that cannot be corrected with surgical excision, such as submental laxity, upper arm laxity, pendulous breasts after breast feeding, and mild periumbilical or suprapubic loose skin following childbirth or weight loss.
Dr. Duncan recently returned from Paris, where she was a featured speaker at The International Master Course for Ageing Skin (IMCAS). Having a passion for clinical research, Dr. Duncan is part of an elite group of physicians chosen to perform studies and clinical trials for device developers around the world. She regularly writes for medical journals and textbooks with recent contributions including chapters on energy assisted body contouring, the physics of radiofrequency and the care and prevention of complications in body contouring.
Excellence in clinical outcome is the purpose of Dr. Duncan’s research. Her innovative approach to a non-surgical blepharoplasty (eyelid lift) was featured at IMCAS, as well as her minimally invasive options for neck rejuvenation. She was also invited to discuss microneedling as a drug delivery device, radiofrequency needling for skin and soft tissue tightening, upper arm contouring and the mechanics of adipocytolysis.
As important as teaching and speaking is to the growth and improvement of our practice, Dr. Duncan’s “happy place” is with her patients, especially in the operating room. It is her desire that every patient experience the thrill of improvement in their problem area, so much so that this area becomes, if possible, a feature they are proud of. Dr. Duncan’s goals for her patients include lasting results with a natural, classically beautiful appearance. By attending these international meetings, she not only maintains the global standard of practice, she stays abreast of the industry’s latest innovations.