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When you are starting to see skin looseness and sagging but it is not pronounced, then it is time to start in-office non-surgical aesthetic skin tightening treatments to prevent and correct early or moderate changes. Non-surgical cosmetic procedures to combat sagging can also be useful in patients who have more pronounced sagging, but who are either not candidates for surgical tightening or who don’t want a surgical procedure and are willing to accept less tightening than they would get with surgery.

There are basically two ways to approach the problem and often the best results are achieved by utilizing both. The first approach are procedures that tighten the skin by increasing collagen and tightening the existing collagen and elastic fibers. The second option is to restore the aging related lost volume with fillers and lift the skin in what has been called a “liquid lift” or “liquid face-lift”.

Current non-invasive aesthetic facial skin tightening procedures employ one of two types of energy—radiofrequency (Thermage, Accent) or infrared light (SkinTyte)—to tighten by heating the area below the surface of the skin. The heat works by two mechanisms, by causing a small injury and inflammation which causes existing collagen to tighten, and as it heals inducing the skin to make new collagen. In any individual patient the amount of tightening may be tilted toward either mechanism, depending on the amount of existing collagen and the ability of the patient to make new collagen.

There are several different branded machines used to tighten skin, and each physician, including me, thinks that the one they use is the best.

The first procedures that were observed to tighten skin were the ablative CO2 lasers, like the original UltraPulse laser we used 13 years ago. Although they were used primarily to treat wrinkles, the heat generated during treatment did give some tightening. But they couldn’t be used on the body, and the prolonged healing, potential pigment changes and redness limited their usefulness and ultimately they were replaced by fractional laser resurfacing. Today the fractional ablative CO2 lasers, Fraxel re:pair and DeepFX, do give some tightening, but have a recovery time, and some risk of scarring and pigment change. They are not used primarily for skin tightening, but for patients who need significant skin resurfacing and who are willing to accept the recovery time.

The original non-surgical treatment developed specifically reduce sagging skin is Thermage, which uses radiofrequency energy to heat the deeper areas of the skin. Because too much heat can damage the skin, before and after each burst of radiofrequency energy a burst of cooling is used to protect the surface of the skin, and the fat below. The heat causes some tightening of existing collagen and production of new collagen over a 6 month period of time. Some patients see immediate results, some see results over time. There is no downtime. I think Thermage, especially the latest generation treatment, works best and most reliably for skin tightening. Your doctor may think differently.

There is definitely variability in results among patients because of patient factors, differences in machine technology, and skin in treatment techniques. I tell patients that because of this variability there is a spectrum of results—on one end are those patients who get really good results, on the other end are those who really don’t see very much change, and in between are those who get some tightening and who are usually satisfied with their results. Patients who are definitely not satisfied are those with moderate or marked looseness who are expecting face-lift like results.

All of the skin tightening treatments work best on patients with some remaining collagen, elasticity and underlying fat; on those who are healthy; non-smokers; those with mild to moderate skin looseness and good underlying muscle tone. They all work less well on those with very thin skin (lacking collagen and fat), smokers, those who continue to tan, and patients over 65 who have decreased ability to make new collagen. And they are not a substitute for a face-lift, although I have some patients, who really need a face-lift but who don’t want one, get some improvement with Thermage and be happy with the results. Because facelifts only surgically remove skin and pull the remaining skin and underlying fat and muscle into place, they do not by themselves produce more collagen and elasticity. For that reason we also sometimes perform Thermage on patients who have had a facelift in the past but who are getting some loosening and want increased elasticity and tightness to the skin.

As we discussed in in some of the previous posts about restoring volume to skin with fillers such as Juvederm, Restylane, Sculptra or Radiesse in a “liquid face lift” also helps to lift skin and gives a more natural look as well. Initially we worried that treatments like Thermage given to skin that had received filler would cause the filler to go away quicker, but now we have found just the opposite. It actually helps patients get better results because the fillers, especially the hyaluronic acid fillers like Juvederm improve the function of the fibroblast cells that produce new collagen. Many of my patients benefit from doing both together.

Realistic expectations are key to satisfaction with non-surgical skin tightening. Patients can’t expect more than a procedure can deliver. Physicians can’t promise more than the technology and the patient’s condition will permit.

Next: Sometimes you need a knife—surgical skin tightening


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