Cosmetic Commentary Journal of Cosmetic Dermatology, 13, 208--211
Patient selection for skin-tightening procedures Marian Northington, MD Cosmetic Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
Summary
Noninvasive skin-tightening devices have become increasingly popular over the last decade to improve skin laxity with minimal risk and recovery time. Proper patient selection improves patient outcomes and satisfaction. There are many devices available for tightening including monopolar radiofrequency, bipolar radiofrequency, fractional radiofrequency devices, infrared devices, combined light and bipolar radiofrequency devices, and intense focused ultrasound devices. There have been shortcomings with tightening devices including inconsistent clinical outcomes. The question arises, why are there inconsistent results and variability among patient outcomes? Variability could be related to different devices, treatment protocols, body area treated, and patient selection. Patient age, degree of laxity, history of smoking, ethnicity, body mass index, and individual patient pain threshold could all possibly contribute to patient response to tightening devices. The literature does not elucidate consistently, which variables are the most important in predicting best patient response. Included is a review of the literature discussing skin tightening and patient selection. Keywords: skin laxity, skin aging, rhytides
Noninvasive skin-tightening devices have become increasingly popular over the last decade to improve skin laxity with minimal risk and recovery time. Although surgical face lifting is the most effective treatment to improve skin laxity, it is also a procedure that involves risks such as scarring, infection, nerve damage, inherent risks of anesthesia, swelling, and bruising. Patients are less tolerant of the risks and prolonged recovery associated with surgical options and are seeking treatment that do not interrupt their daily activities. Patients are satisfied with more modest improvement if it is convenient for them and noninvasive. The difference between results of noninvasive tightening devices and surgery was published by Alexiades et al. who compared fractional radiofrequency Correspondence: M Northington, MD, Cosmetic Dermatology, University of Alabama at Birmingham, TKC 4 FL 2000 6th Ave S, Birmingham, AL, 35233-0271, USA. E-mail: [email protected] Accepted for publication April 19, 2014
208
before and after photographs with face lift before and after photographs. This revealed a 49% improvement in laxity in surgical group and a 16% improvement in the FRF group. The FRF achieved 37% of the results of a surgical face lift. (archives 2010) There are many devices available for tightening including monopolar radiofrequency, bipolar radiofrequency, fractional radiofrequency devices, infrared devices, combined light and bipolar radiofrequency devices, and intense focused ultrasound devices. There have been shortcomings with tightening devices including inconsistent clinical outcomes, need for multiple treatments, shortlived results, discomfort during treatments and costs.1 The question arises, why are there inconsistent results and variability among patient outcomes? Variability could be related to different devices, treatment protocols, body area treated, and patient selection. Patient age, degree of laxity, history of smoking, ethnicity, body mass index, and individual patient pain threshold could all possibly contribute to patient response to
© 2014 Wiley Periodicals, Inc.
Patient selection for tightening procedures
tightening devices. The literature does not elucidate consistently, which variables are the most important in predicting best patient response. Included is a review of the literature discussing skin tightening and patient selection. In 2003, Esparza and Gomez described their findings of 15 patients who had treatment with monopolar radiofrequency (MRF). Only the preauricular areas were treated and 14 of 15 obtained improvement in facial laxity without scarring or tissue wounding. Improvements were noted as soon as 1 week after treatment and continued for 3 months. These authors report that the one patient who did not respond was overweight and had “very heavy cheeks” in comparison with the other patients in the group who were thinner.2 In this author’s experience, patients with excess adipose tissue, especially on the submental area do not respond as well as patients who have predominantly skin laxity without the excess adipose tissue. This type patient benefits most from a combination of neck liposuction with noninvasive tightening a month or so afterward to achieve the most improvement in jawline definition and skin laxity (Figs. 1 and 2). Also in 2003, Hsu and Kaminer reviewed photographs and conducted telephone interviews to assess patient satisfaction with MRF. Sixteen patients were evaluated, and 15 participated in the interviews. Eleven of 16 had cheeks, jawline, and neck treated, 2 of 16 had had the cheeks and jawline treated, and 3 of 16 had cheeks only treated. Five of the 15 reported
Figure 1 Patient who was opposed to a surgical facelift, but wanted to improve the appearance of her neck.
© 2014 Wiley Periodicals, Inc.
. M Northington
satisfactory results, and 10 reported unsatisfactory results. The satisfactory group had higher energy setting and was slightly younger. The average age of the satisfied group was 51, and the average of the unsatisfied group was 58. The comparison of the before and after photographs, however, did not show any significant change in any of the patients. The authors explain that they feel the younger patients respond better because they have a higher percentage of heat labile collagen bonds available to shrink and tighten in response to heat compared with older patients. In older tissue, the heat labile collagen bonds are replaced by irreducible multivalent cross-links. They also explain that the higher energy settings and larger area of skin treated lead to better results.3 Alster and Tanzi agreed that older age may lead to poorer response to MRF in 2004 when they treated 50 patients with mild-to-moderate cheek or neck laxity. Clinical improvement in cheek laxity was seen in 28 of the 30 patients, and improvement in neck laxity was noted in 17 of the 20 patients. The five patients who had no clinical improvement were older than 62 years of age.4 Older age and diminished degree of skin tightening were not a correlation in a study by Edwards et al. in 2013. This study evaluates the improved MRF device released in 2009, which has a vibration handpiece and a treatment tip that more efficiently controls thermal distribution to improve tolerability and outcomes.
Figure 2 Patient was satisfied with her neck after tumescent liposculpture of the neck followed by monopolar radiofrequency (MRF) to the face and neck one month later. Photograph is 1 month postMRF.
209
Patient selection for tightening procedures
. M Northington
Sixty-four patients with mild–to-moderate laxity were treated and surveyed. 80% reported at least mild correction, 29% reported moderate improvement, and 3% reported excellent improvement. Laxity improvement was greater at 4–6 months than 1–3 months. This supports that delayed wound healing plays a large role in tissue tightening. 43% would have the procedure again. There was not a relationship found between younger age and better tightening. However, skin texture improvement was less in older patients.5 In this author’s experience, age is not a reliable variable predicting patient outcome and satisfaction. However, patients with a greater amount of skin laxity are not generally as satisfied with the treatment results as those with less skin laxity. Amount of skin laxity is a better predictor of patient satisfaction than age is. Intense focused ultrasound (IFUS) is another choice in the array of tightening and is effective. There have not been reports to this author’s knowledge that report variability in response with certain patient traits. Lee et al. evaluated 10 patients treated on the face and neck with IFUS and reported an 80% response rate. Two passes at different tissue depths were performed to target the superficial musculoaponeurotic system (SMAS) and the deep dermis/subcutaneous fat septae. The focused ultrasound vibrates tissue and creates friction between molecules. The molecules absorb energy and release heat, which creates thermally damaged
zones in the targeted areas. Eight of 10 patients showed clinical improvement by photograph comparison by blinded evaluators and 9 of the 10 patients reported improvement. The authors do not discuss the possible reasons why two of the patients did not respond.6 Certain body areas may be more likely to respond favorably than other body areas. Alster reported IFUS results on body areas. Eighteen paired areas on the upper arms, medial thighs, extensor knees were treated with two different transducers, one has a focal depth of 4.5 mm and one with 3 mm focal depth. One extremity had a single pass at 4.5 mm depth, and the other paired extremity had dual passes at both focal depths. All areas improved and the dual-treated areas improved more significantly. Improvement continued for 6 months. Thirteen of the 16 patients were highly satisfied and three were dissatisfied. Of the three dissatisfied patients, two had medial thighs treated and one had arms treated. This suggests that the medial thighs do not respond as well as the arms and extensor knees.1 The dissatisfied patients may not have had realistic expectations relating to the degree of improvement possible with noninvasive tightening. If they were expecting all the laxity to disappear, rather than a modest improvement, this would account for the dissatisfaction. Age and degree of laxity were not predictors of response in this study by Alexiades et al. This study
Figure 3 This is a typical result of noninvasive tightening. This is a patient before and 1 month after monopolar radiofrequency treatment. The laxity is noticeable improved with better jawline definition. However, the laxity has not been eliminated. Appropriate patient expectations are the most important variable in patient satisfaction with noninvasive tightening devices.
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© 2014 Wiley Periodicals, Inc.
Patient selection for tightening procedures
reports a 100% response rate of rhytides and 95% response rate for laxity with fractionated radiofrequency (FRF) treatment in 2013. One hundred subjects with mild-to-severe laxity of the face and neck were treated with FRF, and blinded evaluation of pretreatment and post-treatment photographs showed 24.1% improvement in the Alexiades-Armenakas laxity scale at 6 months and 25% improvement in Fitzpatrick wrinkle scale.7 Collagen remodeling and wound healing result from FRF, which will improve laxity as well as skin texture. As the technology advance and our understanding of how these devices work and the specific changes they create in the skin, the clinical outcomes will continue to improve and become more consistent. Additionally, with more experience and improved understanding, treatment protocols will be adjusted to further improve outcomes and provide consistent results. It would be interesting to compare devices in future studies to see which devices produce most tightening and if some technologies are superior to others. Skin tightening is an exciting and advancing area in facial rejuvenation. The best patients to select for these treatments are ones with appropriate expectations. If the patient is expecting elimination of the laxity, he/ she will be unhappy, but if he/she is expecting a natural modest improvement of 20–30%, then the patient will be satisfied. (Fig. 3) Patients who are surgery adverse, poor surgical candidates, young patients with minimal laxity, or patients who have had surgery in the past and are redeveloping laxity are excellent candidates. Patients who need additional tightening after neck liposculpture are outstanding candidates as well. Tightening devices should be avoided in patients with permanent fillers, implantable devices, mental illness, and those who would not be happy with a modest improvement. This author recommends repeat treatments every 6–12 months to maintain and improve results. Also, results are maximized with combination therapy whether it is with fillers to replace lost volume, or with neurotoxins to soften dynamic lines or to relax the platysmal bands and improve the contour of the jawline. Laser resurfacing, whether it is ablative,
© 2014 Wiley Periodicals, Inc.
. M Northington
fractionally ablative or nonablative fractional, is the most beneficial adjunctive therapy. Resurfacing and noninvasive tightening are procedures that work synergistically together to optimize results. Laser resurfacing creates wound healing and collagen remodeling the epidermis and dermis and the tightening devices work deeper the reticular dermis and the subcutaneous fibrous septae. Thus, more volume and layers of tissue are treated which results in more wound healing and greater results. Also, laxity is only part of aging. Eliminating rhytides, dychromias, and diminishing pore size with add to a youthful appearance and improve patient satisfaction. Patients should be knowledgeable that noninvasive tightening is only part of the solution to facial rejuvenation and that greatest improvement occurs with combination treatment.
References 1 Alster TS, Tanzi EL. Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound. Dermatol Surg 2012; 38: 754–9. 2 Ruiz-Esparza JR, Gomex JB. The medical face lift: a noninvasive, nonsurgical approach to tissue tightening in facial skin using nonablative radiofrequency. Dermatol Surg 2003; 29: 352–332. 3 Hsu TS, Kaminer MS. The use of nonablative radiofrequency technology to tighten the lower face and neck. Semin Cutan Med Surg 2003; 22: 115–23. 4 Alster TS, Tanzi E. Improvement of neck and cheek laxity with a nonablative radiofrequency device: a lifting experience. Dermatol Surg 2004; 30: 503–7. 5 Edward AF, Massaki AB, Fabi S, Goldman M. Clinical efficacy and safety evaluation of a monopolar radiofrequency device with a new vibration handpiece for the treatment of facial skin laxity: a 10-month experience with 64 patients. Dermatol Surg 2013; 39: 104–10. 6 Lee HS, Jang WS, Cha YJ et al. Multiple pass ultrasound tightening of skin laxity of the lower face and neck. Dermatol Surg 2012; 38: 20–7. 7 Alexiades-Armenakas M, Newman J, Willey A et al. Prospective multicenter clinical trial of a minimally invasive temperature-controlled bipolar fractional radiofrequency system for rhytid and laxity treatment. Dermatol Surg 2013; 39: 263–73.
211
Patient selection for skin-tightening procedures Marian Northington, MD Cosmetic Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
Summary
Noninvasive skin-tightening devices have become increasingly popular over the last decade to improve skin laxity with minimal risk and recovery time. Proper patient selection improves patient outcomes and satisfaction. There are many devices available for tightening including monopolar radiofrequency, bipolar radiofrequency, fractional radiofrequency devices, infrared devices, combined light and bipolar radiofrequency devices, and intense focused ultrasound devices. There have been shortcomings with tightening devices including inconsistent clinical outcomes. The question arises, why are there inconsistent results and variability among patient outcomes? Variability could be related to different devices, treatment protocols, body area treated, and patient selection. Patient age, degree of laxity, history of smoking, ethnicity, body mass index, and individual patient pain threshold could all possibly contribute to patient response to tightening devices. The literature does not elucidate consistently, which variables are the most important in predicting best patient response. Included is a review of the literature discussing skin tightening and patient selection. Keywords: skin laxity, skin aging, rhytides
Noninvasive skin-tightening devices have become increasingly popular over the last decade to improve skin laxity with minimal risk and recovery time. Although surgical face lifting is the most effective treatment to improve skin laxity, it is also a procedure that involves risks such as scarring, infection, nerve damage, inherent risks of anesthesia, swelling, and bruising. Patients are less tolerant of the risks and prolonged recovery associated with surgical options and are seeking treatment that do not interrupt their daily activities. Patients are satisfied with more modest improvement if it is convenient for them and noninvasive. The difference between results of noninvasive tightening devices and surgery was published by Alexiades et al. who compared fractional radiofrequency Correspondence: M Northington, MD, Cosmetic Dermatology, University of Alabama at Birmingham, TKC 4 FL 2000 6th Ave S, Birmingham, AL, 35233-0271, USA. E-mail: [email protected] Accepted for publication April 19, 2014
208
before and after photographs with face lift before and after photographs. This revealed a 49% improvement in laxity in surgical group and a 16% improvement in the FRF group. The FRF achieved 37% of the results of a surgical face lift. (archives 2010) There are many devices available for tightening including monopolar radiofrequency, bipolar radiofrequency, fractional radiofrequency devices, infrared devices, combined light and bipolar radiofrequency devices, and intense focused ultrasound devices. There have been shortcomings with tightening devices including inconsistent clinical outcomes, need for multiple treatments, shortlived results, discomfort during treatments and costs.1 The question arises, why are there inconsistent results and variability among patient outcomes? Variability could be related to different devices, treatment protocols, body area treated, and patient selection. Patient age, degree of laxity, history of smoking, ethnicity, body mass index, and individual patient pain threshold could all possibly contribute to patient response to
© 2014 Wiley Periodicals, Inc.
Patient selection for tightening procedures
tightening devices. The literature does not elucidate consistently, which variables are the most important in predicting best patient response. Included is a review of the literature discussing skin tightening and patient selection. In 2003, Esparza and Gomez described their findings of 15 patients who had treatment with monopolar radiofrequency (MRF). Only the preauricular areas were treated and 14 of 15 obtained improvement in facial laxity without scarring or tissue wounding. Improvements were noted as soon as 1 week after treatment and continued for 3 months. These authors report that the one patient who did not respond was overweight and had “very heavy cheeks” in comparison with the other patients in the group who were thinner.2 In this author’s experience, patients with excess adipose tissue, especially on the submental area do not respond as well as patients who have predominantly skin laxity without the excess adipose tissue. This type patient benefits most from a combination of neck liposuction with noninvasive tightening a month or so afterward to achieve the most improvement in jawline definition and skin laxity (Figs. 1 and 2). Also in 2003, Hsu and Kaminer reviewed photographs and conducted telephone interviews to assess patient satisfaction with MRF. Sixteen patients were evaluated, and 15 participated in the interviews. Eleven of 16 had cheeks, jawline, and neck treated, 2 of 16 had had the cheeks and jawline treated, and 3 of 16 had cheeks only treated. Five of the 15 reported
Figure 1 Patient who was opposed to a surgical facelift, but wanted to improve the appearance of her neck.
© 2014 Wiley Periodicals, Inc.
. M Northington
satisfactory results, and 10 reported unsatisfactory results. The satisfactory group had higher energy setting and was slightly younger. The average age of the satisfied group was 51, and the average of the unsatisfied group was 58. The comparison of the before and after photographs, however, did not show any significant change in any of the patients. The authors explain that they feel the younger patients respond better because they have a higher percentage of heat labile collagen bonds available to shrink and tighten in response to heat compared with older patients. In older tissue, the heat labile collagen bonds are replaced by irreducible multivalent cross-links. They also explain that the higher energy settings and larger area of skin treated lead to better results.3 Alster and Tanzi agreed that older age may lead to poorer response to MRF in 2004 when they treated 50 patients with mild-to-moderate cheek or neck laxity. Clinical improvement in cheek laxity was seen in 28 of the 30 patients, and improvement in neck laxity was noted in 17 of the 20 patients. The five patients who had no clinical improvement were older than 62 years of age.4 Older age and diminished degree of skin tightening were not a correlation in a study by Edwards et al. in 2013. This study evaluates the improved MRF device released in 2009, which has a vibration handpiece and a treatment tip that more efficiently controls thermal distribution to improve tolerability and outcomes.
Figure 2 Patient was satisfied with her neck after tumescent liposculpture of the neck followed by monopolar radiofrequency (MRF) to the face and neck one month later. Photograph is 1 month postMRF.
209
Patient selection for tightening procedures
. M Northington
Sixty-four patients with mild–to-moderate laxity were treated and surveyed. 80% reported at least mild correction, 29% reported moderate improvement, and 3% reported excellent improvement. Laxity improvement was greater at 4–6 months than 1–3 months. This supports that delayed wound healing plays a large role in tissue tightening. 43% would have the procedure again. There was not a relationship found between younger age and better tightening. However, skin texture improvement was less in older patients.5 In this author’s experience, age is not a reliable variable predicting patient outcome and satisfaction. However, patients with a greater amount of skin laxity are not generally as satisfied with the treatment results as those with less skin laxity. Amount of skin laxity is a better predictor of patient satisfaction than age is. Intense focused ultrasound (IFUS) is another choice in the array of tightening and is effective. There have not been reports to this author’s knowledge that report variability in response with certain patient traits. Lee et al. evaluated 10 patients treated on the face and neck with IFUS and reported an 80% response rate. Two passes at different tissue depths were performed to target the superficial musculoaponeurotic system (SMAS) and the deep dermis/subcutaneous fat septae. The focused ultrasound vibrates tissue and creates friction between molecules. The molecules absorb energy and release heat, which creates thermally damaged
zones in the targeted areas. Eight of 10 patients showed clinical improvement by photograph comparison by blinded evaluators and 9 of the 10 patients reported improvement. The authors do not discuss the possible reasons why two of the patients did not respond.6 Certain body areas may be more likely to respond favorably than other body areas. Alster reported IFUS results on body areas. Eighteen paired areas on the upper arms, medial thighs, extensor knees were treated with two different transducers, one has a focal depth of 4.5 mm and one with 3 mm focal depth. One extremity had a single pass at 4.5 mm depth, and the other paired extremity had dual passes at both focal depths. All areas improved and the dual-treated areas improved more significantly. Improvement continued for 6 months. Thirteen of the 16 patients were highly satisfied and three were dissatisfied. Of the three dissatisfied patients, two had medial thighs treated and one had arms treated. This suggests that the medial thighs do not respond as well as the arms and extensor knees.1 The dissatisfied patients may not have had realistic expectations relating to the degree of improvement possible with noninvasive tightening. If they were expecting all the laxity to disappear, rather than a modest improvement, this would account for the dissatisfaction. Age and degree of laxity were not predictors of response in this study by Alexiades et al. This study
Figure 3 This is a typical result of noninvasive tightening. This is a patient before and 1 month after monopolar radiofrequency treatment. The laxity is noticeable improved with better jawline definition. However, the laxity has not been eliminated. Appropriate patient expectations are the most important variable in patient satisfaction with noninvasive tightening devices.
210
© 2014 Wiley Periodicals, Inc.
Patient selection for tightening procedures
reports a 100% response rate of rhytides and 95% response rate for laxity with fractionated radiofrequency (FRF) treatment in 2013. One hundred subjects with mild-to-severe laxity of the face and neck were treated with FRF, and blinded evaluation of pretreatment and post-treatment photographs showed 24.1% improvement in the Alexiades-Armenakas laxity scale at 6 months and 25% improvement in Fitzpatrick wrinkle scale.7 Collagen remodeling and wound healing result from FRF, which will improve laxity as well as skin texture. As the technology advance and our understanding of how these devices work and the specific changes they create in the skin, the clinical outcomes will continue to improve and become more consistent. Additionally, with more experience and improved understanding, treatment protocols will be adjusted to further improve outcomes and provide consistent results. It would be interesting to compare devices in future studies to see which devices produce most tightening and if some technologies are superior to others. Skin tightening is an exciting and advancing area in facial rejuvenation. The best patients to select for these treatments are ones with appropriate expectations. If the patient is expecting elimination of the laxity, he/ she will be unhappy, but if he/she is expecting a natural modest improvement of 20–30%, then the patient will be satisfied. (Fig. 3) Patients who are surgery adverse, poor surgical candidates, young patients with minimal laxity, or patients who have had surgery in the past and are redeveloping laxity are excellent candidates. Patients who need additional tightening after neck liposculpture are outstanding candidates as well. Tightening devices should be avoided in patients with permanent fillers, implantable devices, mental illness, and those who would not be happy with a modest improvement. This author recommends repeat treatments every 6–12 months to maintain and improve results. Also, results are maximized with combination therapy whether it is with fillers to replace lost volume, or with neurotoxins to soften dynamic lines or to relax the platysmal bands and improve the contour of the jawline. Laser resurfacing, whether it is ablative,
© 2014 Wiley Periodicals, Inc.
. M Northington
fractionally ablative or nonablative fractional, is the most beneficial adjunctive therapy. Resurfacing and noninvasive tightening are procedures that work synergistically together to optimize results. Laser resurfacing creates wound healing and collagen remodeling the epidermis and dermis and the tightening devices work deeper the reticular dermis and the subcutaneous fibrous septae. Thus, more volume and layers of tissue are treated which results in more wound healing and greater results. Also, laxity is only part of aging. Eliminating rhytides, dychromias, and diminishing pore size with add to a youthful appearance and improve patient satisfaction. Patients should be knowledgeable that noninvasive tightening is only part of the solution to facial rejuvenation and that greatest improvement occurs with combination treatment.
References 1 Alster TS, Tanzi EL. Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound. Dermatol Surg 2012; 38: 754–9. 2 Ruiz-Esparza JR, Gomex JB. The medical face lift: a noninvasive, nonsurgical approach to tissue tightening in facial skin using nonablative radiofrequency. Dermatol Surg 2003; 29: 352–332. 3 Hsu TS, Kaminer MS. The use of nonablative radiofrequency technology to tighten the lower face and neck. Semin Cutan Med Surg 2003; 22: 115–23. 4 Alster TS, Tanzi E. Improvement of neck and cheek laxity with a nonablative radiofrequency device: a lifting experience. Dermatol Surg 2004; 30: 503–7. 5 Edward AF, Massaki AB, Fabi S, Goldman M. Clinical efficacy and safety evaluation of a monopolar radiofrequency device with a new vibration handpiece for the treatment of facial skin laxity: a 10-month experience with 64 patients. Dermatol Surg 2013; 39: 104–10. 6 Lee HS, Jang WS, Cha YJ et al. Multiple pass ultrasound tightening of skin laxity of the lower face and neck. Dermatol Surg 2012; 38: 20–7. 7 Alexiades-Armenakas M, Newman J, Willey A et al. Prospective multicenter clinical trial of a minimally invasive temperature-controlled bipolar fractional radiofrequency system for rhytid and laxity treatment. Dermatol Surg 2013; 39: 263–73.
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