Nonsurgical skin tightening: Field remains open for significant improvement

November 1, 2008

Nonsurgical skin-tightening procedures based on deep-tissue energy delivery have many attractive features for consumers and physicians. The number of devices available is expanding, but despite the growth in this industry, results remain variable and modest.

Key Points

"The good news is these minimally invasive procedures produce minimal to, at most, moderate discomfort, and they are associated with minimal downtime and no significant complications.

"However, for reasons still unclear, some people respond better than others, and in many cases, the effect seems insufficient to warrant the cost and duration of treatment," Dr. Alam says.

Furthermore, the fact that they are very safe for ethnic skin is an important consideration.

"Many companies are working in this area, and perhaps we may need to see change in the underlying technology to reach the goal of achieving more tissue shrinkage and tightening while maintaining the current good safety profile," Dr. Alam says.

The indication for nonsurgical tightening and lifting is treatment of middle-aged or young skin laxity. This procedure is not appropriate for patients with severe skin sagging and will not address crepe-like skin or pigmentary abnormalities.

Marketplace demand

Stimulated by the marketplace demand, the number of companies manufacturing and developing devices for nonsurgical skin tightening and lifting has been growing rapidly.

The monopolar radiofrequency device (ThermaCool™, Thermage®) was the innovator technology in the industry. Launched in 2002, initial experience with its use for facial skin-tightening procedures showed that a significant proportion of treated patients - at least 25 percent - responded poorly.

In addition, complications included significant pain along with risks of burns, skin depressions and tissue atrophy.

While treatment-related discomfort remains an annoyance, modifications in the treatment parameters and protocol have successfully improved the safety profile.

In addition, applications have been expanded to include tightening of the abdomen, buttocks and legs. However, inconsistent efficacy remains a limitation with this and newer modalities.

These newer options for nonsurgical skin tightening include devices based on use of bipolar radiofrequency energy, light and laser, and some devices use vacuum in combination.

An ultrasound-based device is also in development (Ulthera). Ultrasound may potentially overcome some of the obstacles encountered using other technologies to cause deep tissue shrinkage, Dr. Alam tells Dermatology Times.

"The holy grail is to deliver energy to the fascia, because, presumably, with very deep penetration, it may be possible to induce contraction that would be sufficient to cause clinically significant tightening. Apart from gamma radiation, ultrasound is the only kind of energy that can be introduced arbitrarily to that level," Dr. Alam says.

In initial testing using the investigational ultrasound-based system for brow elevation, results achieved were similar in magnitude to those reported with currently available technology.

However, the improvement was documented using a complicated algorithm and found to be reproducible.

Targets for the future

Going forward, it will be important to develop better methods for measuring efficacy, Dr. Alam says.

"There are no objective ways to measure the tightening achieved. As a result, outcomes are being judged based on 'before' and 'after' pictures showing very subtle changes that make it difficult to tell how much improvement has occurred," Dr. Alam says.

"For now, blinded-rater evaluations of standardized photographs are the best we can do. However, there remains a need for better techniques that avoid biased, subjective measures so that we can see what works and what doesn't," he says.

Reader, beware

Dr. Alam cautions his colleagues to read published reports on nonsurgical skin tightening with a critical eye and not to be convinced by explanations of the mechanisms of action.

"Please consider this information with some skepticism. It is easy to postulate mechanisms but hard to prove they are operative," Dr. Alam says.

He also notes that some studies may use instrumental techniques to provide some objective measure of efficacy. However, readers should consider closely whether the variable being measured has any clinical significance. Reports of patient satisfaction can also be deceiving, Dr. Alam says.

"Patient satisfaction is a poor measure of efficacy, since clinical trial participants who are receiving treatment at no cost are prone to be happy. Furthermore, they want to please the investigator and so will try to be happy even if they are not," he explains.

Readers should also consider that data on immediate post-operative results are also of limited usefulness, considering the treatment is associated with immediate swelling, which in turn will make the skin seem tighter and less wrinkled.

"Future research in this field needs to address the persistence of the benefits achieved," Dr. Alam says.

Disclosure: Dr. Alam is an investigator for Ulthera.

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