Fat reduction treatments have advanced rapidly over the past decade, but this is only half of the story. Fat reduction can sometimes lead to excess skin, which can be troublesome and concerning for patients. For this reason, skin-tightening modalities have been growing with the rise of body contouring. In this article, Sam Ghani explores the options for non-invasive and minimally-invasive skin tightening techniques, which can be the final step in achieving a patient’s body goals
In recent years, there has been a huge rise in the demand for non-invasive treatments for skin tightening. For many years the gold standard for addressing loose or excess skin has been in the surgical domain, in the form of skin removal treatments, such as face lifts, arm lifts, neck lifts and abdominoplasty. Although the results of such procedures are impressive, they are associated with significant morbidity, as well as a long downtime and significant expense. Furthermore, these procedures work by removing excess skin and pulling the residual skin over the same area, which results in the skin appearing to be more taut. However, the skin quality itself is essentially unaltered by this process. With a shift towards non-invasive treatments for aesthetic enhancements, there has been a strong drive towards the development and successful implementation of technologies that can deliver comparable skin tightening effects without the complications of surgery.
The need for skin tightening technologies
The ageing process results in a cumulative depletion of collagen and elastin, as well as loosening of fibrous septae. These factors combine to increase skin laxity. This is particularly worsened by the effects of photoageing on the face. Large fluctuations in weight and the after-effects of pregnancy result in increased skin laxity around the abdomen, thighs and arms. Hormonal surges heighten the effects of this with the development of cellulite (fibrodysplasia) around the thighs and buttocks.
In 1997, Hayashi et al published a landmark study in which they described the histological changes affecting collagen fibrils when exposed to temperatures reaching around 65oC (Hayashi et al, 1997). They found that heat resulted in shrinkage and denaturation, followed by de novo synthesis, remodelling and regeneration. More recently, this process has been further evaluated (Lolis and Goldberg, 2012). Heat exposure to the dermal and subdermal layers of the skin results in denaturation of collagen and disruption of the fibrous septae present in the subdermal layer. This subsequently results in neocollagenesis, shrinkage of the fibrous septae, and thickening of the adjacent epidermis. The net result of this is an increase in collagen, reduction in elastin and shortening of the fibrous septae, producing a significant skin tightening effect (Lolis and Goldberg, 2012). Hence treatment modalities able to specifically target this region of the skin with focused heat energy can result in skin tightening effects. Although not as significant as surgery, the effects can nevertheless be effective (Lolis and Goldberg, 2012) and appreciated by those patients seeking a non-invasive alternative with a shorter downtime and reduced morbidity.
The ideal treatment option
The ideal non-invasive or minimally invasive skin-tightening treatment should be able to specifically target heat energy at the dermal and subdermal layers of the skin in the region of concern, leaving other structures in tact and unaffected. Over the last decade, there has been an explosion in a variety of technologies claiming to be able to offer exactly this. This review summarises the different skin tightening modalities available ,with a brief evaluation of the published literature.
Non-invasive approaches to skin tightening can be broadly divided into ablative and non-ablative technologies. In addition, it is important to note that not all modalities are suitable for all areas. The majority of energy-based devices are focused on providing skin tightening effects to the face—specifically the forehead and cheeks. Few treatments have demonstrable benefits in skin tightening for the rest of the body, including the neck, abdomen, arms and thighs.
Fractional and non-fractional ablative lasers
Ablative approaches to skin tightening involve the delivery of energy to all layers of the skin, resulting in vapourisation of the epidermis and resultant heating of the dermal and subdermal layers. Ablative approaches that have demonstrated a clear improvement in skin laxity include ablative lasers (fractional and non-fractional). Although not as invasive as surgery, ablative skin tightening treatments are still associated with significant downtime for the patient. They are painful procedures that can also be associated with significant morbidity. Fitzpatrick et al conducted a comparative study using a CO2 ablative laser and Erbium-Yag laser (Fitzpatrick et al, 2000). They demonstrated an average skin tightening of 43% and 42% respectively, which reduced to 34% and 36% at 6 months post treatment. They identified less dramatic results with fractionated carbon dioxide lasers in their clinical practice over the same period of time; however, this was not included as part of the study. However, there were significantly more side effects noted with non-fractionated approaches, including increased recovery time, increased bruising and higher pain scores (Fitzpatrick et al, 2000).
As with invasive surgery, there has been a shift away from ablative non fractional lasers. The recent popularisation of plasma technology has yielded a unique, essentially fractionated ablative skin tightening technique that has been shown to be particularly effective on delicate areas of the face, for example the upper and lower eyelids. De Goursac published the findings of a retrospective review of 35 patients who received a non-surgical blepharoplasty for periorbital rejuvenation using a device known as Jett Plasma (De Goursac, 2018). Plasma is considered the fourth state of matter, which is created by adding energy to a gas.
The Jett Plasma is a handheld device that passes a direct current through air to result in a beam of energy that is precise and has a beam width of less than 0.1 mm. De Goursac treated the periorbital region of 38 patients with a mean age of 48 years with the Jett Plasma device using her own previously published protocol (De Goursac, 2018). De Goursac managed to achieve a significant improvement in the drooping of the upper eyelid in the majority of patients documenting an average lift of 2 mm, with few side effects (De Goursac, 2018).
Proponents of the plasma pen have suggested that the same technique can be used for skin tightening applications on any part of the body, including the abdomen, arms and neck. In the author’s opinion, this is probably not the case, as there is very limited energy delivery to the dermal and subdermal regions, with likely no effect on the subdermal fibrous septae, irrespective of the number of ‘dots’ placed. In addition, the force of vectors required to deliver effective skin tightening in the abdomen and thigh areas are likely to require large amounts of energy delivery that cannot be generated using the plasma pen. The procedure is also extremely tedious and time consuming over larger areas.