The Holy Grail it seems in plastic surgery, at least over the last 15 years or so, is skin tightening without surgery. We know that a modern facelift can restore a youthful shape of the face as well as tighten the overlying skin of the face and neck. Because a facelift necessitates making of incisions, some type of anesthesia, as well as the perceived downtime away from work or family, there are a multitude of patients who would opt for a noninvasive or minimally invasive modality to accomplish the same goals. While we do have neurotoxins such as Botox, Dysport and Xeomin, which can paralyze underlying muscles rendering the overlying crease less deep, as well as a plethora of different fillers, either made from hyaluronic acid or other substances, to make the face more youthful, none of these entities will tighten the overlying skin or improve upon fine lines for texture.
For the last 20 years or so we have had ablative lasers using wavelengths of carbon dioxide or Erbium, whether in a fractional or a full field coverage of the face that can produce skin tightening, these lasers need to deliver their energy to the deeper portion of the skin called the dermis and do not have the ability to spare the outer part of the skin called the epidermis. Therefore, when doing ablative laser resurfacing, when the outside layer of skin is removed, some downtime is necessary for healing and, until the outside skin has grown back, make up cannot be used during this healing process. This forced patients scheduling these more aggressive procedures during periods of time in which they could accept these downsides in order to obtain a result of skin tightening, correction of texture and fine lines, as well as the improvement in brownish discolorations.
Some of the newer technology, have used radiofrequency (RF) as a method of tightening skin. These radiofrequency waves, commonly used in telecommunications, have also been used in surgery for over 75 years, mostly in surgical or dermatological applications for both removal of superficial skin blemishes or cutting, and coagulation of blood vessels during surgery. RF works by rapidly stimulating the oscillation of molecules causing internal friction and thereby heat. The heat produced by RF is thought to ‘injure’ the deeper part of the skin causing an inflammatory response by the patient producing new collagen and elastin. Both of these entities, when increased, produce a more elastic and tightened skin appearance.
The first wave of RF devices applied the heat from the outside-in with some type of method of cooling to allow the heat to preferentially be absorbed in the dermis. Because of the human intolerance of outside-in heat of temperatures in excess of 43°C, there was some limitation in how much tightening one could get in a single session. Multiple weekly or biweekly treatments are necessary to produce the desired effect.
The next advancement in the application of RF was to place the heat under the skin using a long insulated needle. Here, using local anesthesia, higher temperatures at the bottom of the skin could be reached and still tolerable by the patient. The technique is called ThermaTyte and we have had this for several years now. It’s very effective for skin laxity around the belly button as well as neck. It does have some downtime, as a fair amount of dilute numbing medicine needs to be placed beneath the skin to make it tolerable.
The latest advancement in the application of RF for the tightening of skin utilizes the placement of this energy through the skin using tiny, hair size needles, known as microneedling. Microneedling involves, either with a roller or piston type stamping method, the insertion of an array of needles into the skin. No skin is removed and the hole simply closes within hours. While open, topical application of serums, that would otherwise not be absorbed, can be placed over the skin allowing them to gain entry to the deeper layers. The improvement in the quality of skin texture is limited only to the length of the linear hole that is made into the skin. Radiofrequency heat energy can be added to the end of the needle so microscopic injuries in the deeper portion of the skin can be made. We can control not only how much energy, but also how long the energy is applied, as well as the exact depth of its placement using a computerized screen. This new device is called Vivace.
Vivace uses an array of 36, 1/3000th of an inch wide, goldplated needles attached to a computerized mechanism that when placed on the skin can pierce the skin and deliver the radiofrequency energy in a fraction of a second. The technique does require the topical application of a numbing cream for about 45 minutes prior to the procedure. Because not all of the skin can be treated in one session, a series of treatments is necessary to produce the desired result. Multiple treatment depths can be done in the same session. We are commonly treating skin laxity of the face, stretch marks of the abdomen and legs, active acne as well as acne scarring using this new exciting technology.
So far, we have found this technique to be extremely useful in producing nice results in all the patients. Because the energy bypasses the outside layer of the skin, any skin color or amount of skin tan is amendable to this treatment regimen. After the procedure, we have seen that the skin is merely red or pink for a few hours. Makeup can easily be applied the following day. Some patients have found that there is a gritty feeling texture to their skin but is usually not visible under makeup. We recommend a series of at least four treatments at 4 to 6 week intervals. It seems we finally have a method to treat all patients in all seasons with issues of acne scars, stretch marks, skin laxity of different areas of the body.