Dr. Annie Chiu discusses the advantages—and limitations—of several minimally invasive devices used to tighten aging skin.
Annie Chiu, MD, is Founder of The Derm Institute, Redondo Beach, California
“From a nonsurgical standpoint, skin tightening and laxity are probably the biggest challenge in the aesthetic field. I think it’s probably because it’s such a multifactorial process…. Likely combination treatments will be necessary for a clinically significant outcome,” said Annie Chiu, MD, who presented “Minimally Invasive Lift and Tightening Procedures” at the 2021 ASDS Annual Meeting.
“We’re trying to approach it in various one-dimensional ways, and patients don’t want to necessarily invest in multiple pricey procedures, like energy-based devices and injectables, to really address all the epidermal, dermal, and subcutaneous [tissues],” she said.
Energy-Based Devices vs. Biostimulatory Fillers
Although there are many tools available for nonsurgical skin tightening, most people think first and foremost about energy-based devices, said Dr. Chiu.
“The idea is using heat—like throwing a pair of jeans in a dryer—to retighten the loose collagen and elastic tissue fibers.”
However, lack of consistency in results, patient discomfort, multi-session treatments, and the sheer capital investment for practices to obtain energy-based devices have spurred interest in other minimally invasive options.
“In the last few years, we’ve really tried to explore the use of biostimulatory fillers to treat skin quality, including laxity, not really because one is necessarily better than the other, but the truth is we still haven’t found something that is consistent in terms of outcomes across the board. It is difficult to predict which patients will have an appreciable improvement versus those who really can’t see results that are aligned with the cost of these procedures. Also, energy-based devices often have a significant level of pain to achieve settings that truly tighten, and sometimes that simply is not tolerable for patients.”
And for those devices that actually work, results can be hard to predict in order to establish a realistic expectation of results for the patient, said Dr. Chiu.
“I haven’t found them to give reliably predictable improvement for me to feel good about the value against patient pricing.”
By contrast, biostimulatory fillers provide the opportunity to approach and sculpt areas artfully, and in a customized way, she said. In a financially practical sense, especially for newer dermatology practices, there’s less capital investment required when you can use injectables versus purchasing a skin tightening device that often also comes with consumable costs.
Additionally, “In my experience, most patients have some sort of consistent appreciable results with biostimulatory fillers likely because some degree of laxity is almost always caused by subcutaneous volume loss and skin quality changes.”
Studies have shown a histological increase of neocollagenesis and elastic fiber production with some biostimulatory products, as well, said Dr. Chiu.
“…so you are not improving just collagen, but also elastic tissue production, which obviously addresses tightening.”
The Thread Option
Injectable threads are another nonenergy-based device that can be used for minimally invasive skin tightening with immediate gratification, which is what patients want nowadays if they are doing a nonsurgical intervention, said Dr. Chiu.
“If there’s mild to moderate laxity and you place barbed threads in the right vectors, and don’t overuse them and use them in combination with other products, I think they do give a nice lift in certain areas like the jawline and jowl area.”
More significant skin laxity generally requires a surgical approach, she said.
“When used correctly, I’ve had patients who are very happy with [injectable thread] results not just initially but they can provide improvements for up to a year.”
According to Dr. Chiu, threads can be used to address laxity not only in the face and neck, but also on the body, including the décolleté and knee areas.
“I’ve used them in various areas of the body, including the upper chest, abdomen, and for the upper knee area.”
Keeping it Real
In reality, delivering the best minimally invasive skin tightening results isn’t a contest between energy and nonenergy devices. It’s about how you combine them, said Dr. Chiu.
“All providers know, in an ideal world, that combination treatment is always the best. I’m a big believer in learning some of the biostimulatory nonenergy-based procedures available to improve skin tightening…I think it’s just worth learning so you can add both energy and injectable approaches to your toolbox to help patients.”
Regardless of the skin tightening approach, dermatologists need to ensure patients have realistic expectations, said Dr. Chiu.
“If there’s a ton of volume loss and significant skin laxity, patients are going to overspend on these non-surgical procedures with very little to no improvement that has durability. If it’s clear the laxity cannot be appreciably addressed with a reasonable amount of threads, those patients are not going to respond in any clinically significant way to tightening devices. There is a point in which you just have to say, this is either going to be surgical or the improvements we’re going to get are going to be disappointing or mild.”
But “mild” may be enough for some patients, said Dr. Chiu, if they understand that improvement could be just in skin quality.
“You might get improvement in the skin quality, so it looks less crepey. And don’t forget, that all kind of gets lumped into what we describe as ‘laxity.’”
Thin skin, atrophied skin, crepey and crinkly skin that feels loose—minimally invasive approaches can improve some of these patient complaints, said Dr. Chiu.
“You can improve skin quality and maybe slow down the aging process preventatively… and that’s the conversation I really have with patients.”
Disclosure: Dr. Chiu is a consultant for Galderma, Merz, Solta, Abbvie, and Cynosure.