Where Are We in 2024? A Q&A on Non-Surgical Skin Tightening

The popularity of non-surgical skin-tightening techniques has increased substantially in recent years, along with the growing array of procedures and ongoing improvements in devices used to combat mild to moderate skin laxity of the face and body.¹ In addition, several new and emerging developments promise to keep the momentum going in this ever-evolving area while adding to the range of options for personalized treatment planning.

To gauge expert insights about the current state of non-surgical skin tightening, we checked in with Anne Chapas, MD, director of UnionDerm and instructor of dermatology at Mount Sinai Medical Center in New York, New York, and Erez Dayan, MD, director of Advance Plastic Surgery in Reno, Nevada.

BROADLY, HOW WOULD YOU DESCRIBE THE CURRENT LANDSCAPE OF NON-SURGICAL SKIN-TIGHTENING TREATMENTS?

Dr. Chapas: We’ve been performing non-surgical skin tightening with devices for over 20 years, mostly with heat-based energy devices that create neocollagenesis by raising the temperature of the dermis. In addition, I think there are a lot of interesting things going on in skin tightening with dilute injectables like Radiesse and Sculptra.^2,3 Those are two ways that that practices are using different modalities for skin tightening and sometimes we’re even using them in combination.

The dilute injectables are more biostimulatory injectables rather than hyaluronic acid-based injectables. With Radiesse and with Sculptra in their dilute forums, they seem to create new collagen and elastic tissue. We’re using it a lot on the body for that indication rather than for volumizing, which is what their previous indications were for. While hyaluronic acids are being used more for volumizing as well as fine lines, and now are even used for skin boosting, the dilute Radiesse and Sculptra are really used more for their biostimulatory capacity.

Dr. Dayan: Nonsurgical skin-tightening treatments have significantly evolved over the past 5 years. Compared to the early skin-tightening technologies of 20 or 30 years ago, which had very limited temperature control, we now have methods to deliver efficient heating to the soft tissue envelope and deeper levels with tighter temperature control. This not only makes these technologies safer but also far more effective.

Skin-tightening technologies involve a relationship between temperature, time, and duration of treatment. This follows what we call the Arrhenius relationship, meaning that lower temperatures for longer periods of time will produce a comparable skin-tightening effect as higher temperatures and shorter periods of time. The ability to control the temperature and duration of treatment is essential to achieving effective results.

In addition to better technology, complementary methods such as electric muscle stimulation (EMS) have improved results by addressing deeper muscle layers which are important to the overall soft tissue contour and aesthetic.⁴

Lastly, combination therapies have proved to be effective. For example, we are able to address loss of volume in areas of the midface with soft tissue fillers or fat transfer and then tighten laxity of the lower face and neck areas with radiofrequency technology to produce comprehensive minimally invasive results for patients.

WHAT ARE THE MOST EXCITING RECENT INNOVATIONS IN NON-SURGICAL SKIN TIGHTENING?

Dr. Chapas: We’ve been doing these energy-based devices for 20 years, and I think the results are becoming more predictable and reproducible. We’re also looking at mechanical skin tightening with micro-coring. With the energy-based devices, some of the exciting developments include technologies like Sofwave, where we’re now getting more predictable heating underneath the skin in a specific density with cooling.⁵ That’s one of the things we’re doing quite a bit in my practice. The other treatment that has been really exciting this year is micro-coring, which is getting away from heat-based devices to just mechanically remove excess skin to create skin tightening.⁶

Dr. Dayan: One of the most exciting recent innovations has been deep fractional radiofrequency or radiofrequency microneedling that has the ability to reach up to 8 mm deep.^7-9 The Morpheus8 body device specifically has really impacted our practice because it allows us to generate deep heating of fibroseptal networks in body areas. We typically perform this treatment using topical anesthetics. This technology has burst mode, which allows for multiple layers of heating in one pulse, and vulcanization technology, which effectively tightens the deeper fiber septal networks.

The use of combination therapies is another important advance. Especially in body contouring, we now have combination therapies that address different components such as skin laxity, muscle, and lipodystrophy – these were not previously available. We can now customize treatments to unique patient needs. For example, some of our patients have minimal fat excess but are bothered by skin laxity, so we can prioritize radiofrequency skin tightening. For patients who desire more muscle hypertrophy, we can priorities EMS.⁴

Other notable advances include the precision and control of aesthetic technology. For example, we’re able to deliver radiofrequency energy more efficiently and in a more controlled fashion with the advances of bipolar radiofrequency devices that have thermal regulators embedded in them.¹⁰ The radiofrequency devices of 20 years ago did not have this ability, and treatments were not as efficient and led to thermal injury in some cases due to lack of temperature control.

HOW HAVE PATIENTS GENERALLY RESPONDED TO THESE NEWER TECHNIQUES?

Dr. Chapas: I think patients are really interested in any types of non-surgical or less invasive skin-tightening techniques. Surgery is still the gold standard, but I think a lot of people had surgery during the pandemic and now we’re kind of back to our usual interest in non-surgical skin tightening. There was definitely a time when people weren’t working or traveling and had more time on their hands, and more people were going in for surgical treatments. Now I feel like that pendulum has swung back and they’re more interested in what they can do quickly to look better but without the downtime required with surgery.

Skin tightening is a huge area of interest. Clinicians always ask me if they should add something to their practice, and I tell them that if they don’t offer skin-tightening procedures, they’re missing a big need for their patients.

WHAT ARE SOME OF THE MOST NOTABLE ADVANCES CURRENTLY ON THE HORIZON IN THE REALM OF NON-SURGICAL SKIN-TIGHTENING TREATMENTS?

Dr. Chapas: We’re looking at better ways to do ultrasound tightening, and Sofwave is launching new tips for different areas of tightening on the body. They recently launched a precision tip, which is good for small areas like the eyelids and the upper lip, and they’re launching a body-tightening tip in early 2024.

With micro-coring, we’re going to see improvements in how we do the technique in areas other than the jawline and submental areas; they’re working on different types of depths of the needles, different kinds of vacuum with the micro-coring. Another company is offering a sort of 3D tightening with a 1550-nanometer laser. The device is called MIRIA, and it’s a new way to do energy-based tightening with improvement in fine lines and wrinkles and scars.¹¹

Dr. Dayan: I think the next phase of advancement in skin tightening is going to center around restorative therapies that will phase down synthetic treatments such as threads and fillers and move us toward more biologic solutions. Studies are coming out to show that fillers last far longer than we think and can cause injury to lymphatics, especially in the periorbital region.¹² I believe we are reaching a point where aesthetic technology is going to be able to address skin laxity and patients may not need to depend on “camouflage” treatments such as fillers or threads as much and may be able to address core issues such as skin laxity. Also, there are new technologies that may be able to grow a patient’s own fat in precise locations and re-volumize without the need for synthetic injectables.

WHAT TOPICS SHOULD BE THE FOCUS OF FUTURE RESEARCH REGARDING NON-SURGICAL SKIN-TIGHTENING APPROACHES?

Dr. Chapas: We need to continue to improve our understanding of what causes skin laxity. Is aging, weight changes, genetics? What’s are the differences between men and women and between different races and skin types? I think that’s where we need to direct some of the research – toward a better understanding of what’s happening at the most basic scientific level to really then develop treatments to change that process.

Dr. Dayan: Future research will focus on optimal stimulation of collagen from a molecular biology level. We still have to identify the optimal frequency, temperature, and duration of treatments. It will also be important to determine which additive treatments would bolster this effect and optimize longevity of the results. —by Tori Rodriguez

Disclosures: Dr. Chapas reported that she is currently an investigator and consultant for Sofwave and a consultant for Cytrellis. Dr Dayan reported that he is a key opinion leader for InMode and also receives book royalties from Thieme and Elsevier.

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