In the modern era of aesthetics, we deal with many challenges and concerns. Of these problems, skin laxity is a complex issue that may have multiple etiologies with each patient, such as loss of elasticity, collagen breakdown, lack of structural support due to volume loss, and topographical changes in the skin. Before considering an invasive surgical intervention, skin laxity may be addressed using a multimodal approach with minimally to noninvasive energy-based devices, neuromodulators, and soft-tissue augmentation fillers.

Noninvasive energy-based devices have become popular with patients and physicians due to the associated decreased post-procedural downtime. Several modalities exist in this space; however, radiofrequency (RF) and ultrasound (U/S) are among the most used to address skin laxity of the face and neck when the degree of laxity is mild to moderate and when the physician is confident that energy-based devices will provide adequate outcomes. ^, RF and U/S for skin-tightening are also indicated when a patient decides that a deep-plane facelift is more invasive than what they can tolerate or if they have any underlying condition or situation where surgery would be contraindicated. RF has various configurations, such as monopolar, bipolar, and multipolar. The energy generated by an RF device can be delivered through different forms, including stamping, fractionation (RF microneedling), and noncontact/hands-free devices. RF delivers energy that, through tissue impedance, is converted into heat, which results in decreased distention of the loose connective tissue through collagen denaturation.

U/S devices deliver high-intensity focused ultrasound (HIFU) energy through distinct proprietary mechanisms. How energy is delivered includes microfocused ultrasound with visualization (MFU-V) (Ultherapy System; Merz North America, Raleigh, NC, USA), where increased energy penetration targets deeper skin structures and muscles. U/S energy may also be delivered through nonfocused high-frequency synchronous ultrasound parallel beams (SUPERB) (Sofwave; Sofwave Medical Ltd., Israel) that target more superficial skin layers up to the mid-dermis. Neocollagenesis and neoelastogenesis are also achieved using U/S energy through a mechanism different from RF.

There are various dermatological conditions where the above devices play a helpful role. RF and RF microneedling (RFMN) can address skin rejuvenation, acne scarring, acne vulgaris, striae, cellulite, and axillary hyperhidrosis. ^, U/S modalities mainly address skin laxity; however, recent data have demonstrated improvement in patients with cellulitis. U/S devices have proven effective with eyebrow ptosis, achieving a lifting effect and improving visual field function and overall cosmesis. ^,

RF is one of the safest modalities for skin-tightening. It is also often used safely across all Fitzpatrick skin types. However, specific risk management considerations are required when using RF. For example, RF therapy is contraindicated in patients with pacemakers and implantable cardioverter-defibrillators (ICDs) due to the potential risk of device interference. RF, especially RFMN, is also contraindicated in patients with active infections (e.g., bacterial, viral, or fungal) and pregnant or lactating persons, as there is limited safety evidence for the latter. Having metal implants near the area to be treated is also a contraindication of RF and RFMN due to the potential risk of heating the metal implant and causing thermal burns. For patients with metal implants not near the target area, using bipolar RF is strongly advised, as radiofrequency will be limited to the treatment area between the electrodes. Patients with metallic dental implants can receive RF therapy. Relative contraindications for RF and RFMN are unrealistic patient expectations, history of significant scarring or keloids, history of orolabial herpes simplex virus (HSV), previous deep chemical peel and deep laser resurfacing, prior surgery or skin grafts, recent or concomitant use of isotretinoin, and active dermatologic diseases that exhibit the Koebner phenomenon (e.g., vitiligo, psoriasis, lichen planus, among others). ^,

Treatment with MFU-V or SUPERB is contraindicated in patients with the following conditions under the treatment area: open wounds or lesions, severe or cystic acne, and active implants (e.g., pacemakers or ICDs) or metallic implants. ^, Relative contraindications for MFU-V are treatment over areas with mechanical implants, dermal fillers, and breast implants. Treatment over an existing keloid is not recommended. MFU-V has not been evaluated and may not always be recommended to be used with children, persons who are pregnant or lactating, active systemic or local disease that may alter wound healing, hemorrhagic or hemostatic disorders, epilepsy, Bell’s palsy, diabetes mellitus, autoimmune disease, and infections (e.g., HSV).

Similar to MFU-V, the relative contraindications for SUPERB, per the manufacturer, are its use with persons who are pregnant (or planning to become pregnant) or lactating, persons having given birth less than 3 months ago, presence of any active systemic or local infections, presence of active local skin disease that may alter wound healing, history of chronic drug or alcohol use, significant scarring in the area to be treated, and presence of a metal stent or implant in the facial area. ^, Treatment with SUPERB is also not recommended directly over areas with a dermal filler or in people who have used isotretinoin or other systemic retinoids within the past 6 months. It is also not recommended for those who have taken psychiatric drugs, antiplatelets, or anticoagulants within the past 2 weeks.

Appropriate patient education and screening are essential to ensure the patient meets indications for treatment and contraindications are ruled out. Relative contraindications or precautions should be thoroughly discussed with the patient before agreeing to treatment with RF, RFMN, or U/S. Also, at the physician’s discretion, any physical or mental condition that might make it unsafe for the patient to be treated should be discussed with the patient before an informed decision is taken.

This chapter will focus on radiofrequency and ultrasound skin-tightening modalities used on the face and neck.

Overall, the technique will vary depending on the type of modality chosen and the specific platforms or devices being used. Proprietary technology allows for sufficient treatment variation, even within the same device class, allowing the user greater control over the treatment.

RF and U/S therapy are largely tolerable; however, mild-to-moderate patient discomfort is often reported. Therefore, patient preparation is paramount for a safe and effective treatment and patient experience. Before treatment, the patient is counseled regarding the energy-based modality to be used, and the topical anesthetic of choice is then placed over the area to be treated. Depending on the patient and their degree of tolerating discomfort, anxiolytics (benzodiazepines being the most widely used) may be considered. Before starting any treatment, the area to be treated needs to undergo adequate antiseptic preparation. Effective antiseptic agents include 70% isopropyl alcohol (IPA), 0.01% to 0.03% hypochlorous acid (HA), 5% povidone-iodine, and 4% chlorhexidine gluconate. Antiseptic selection will depend mainly on body-site location, where IPA and HA are often preferred for facial treatments, with HA showing efficacy against biofilm. Proper aseptic technique is essential when opting for a minimally invasive modality, such as RFMN.

The goal of skin-tightening via RF treatment lies in using controlled heat to stimulate collagen remodeling. Skin-tightening with RF can be done using monopolar devices that result in volumetric heating and bipolar devices that achieve more superficial or localized nonvolumetric heating. These devices are often used in a stamping method, and areas such as the face and neck can be marked with a grid. Multiple passes with decreased energy have been proposed to make treatments more tolerable, allowing for increased patient comfort without compromising results.

RFMN has the advantage of delivering RF energy to specific deep layers of the skin while benefitting from the mechanical effect of microneedling, which also aids in neocollagenesis and neoelastogenesis. It is important to note that RFMN may have insulated and noninsulated needles. Noninsulated needles will deliver RF energy through the entire needle length. In contrast, insulated needles will only deliver RF energy through the distal tip of the needle, avoiding epidermal thermal damage. The latter is often better tolerated and the delivery method of choice when treating patients prone to pigmentary disorders. Several RFMN platforms with distinct proprietary technology and features are currently available. However, the overall technique is similar. They often require the handpiece to be perpendicular to the skin, ensuring adequate coupling over treatment areas, prioritizing visual improvement, such as the lower medial to superolateral face. The following optimal RFMN settings have been proposed: 67°C, 3 to 4 seconds delivery duration, 3- to 4-mm spacing between applications, and 1.3- to 2-mm penetration depth equivalent to the reticular dermis.

Ultrasound energy is known to reach deep tissue planes in a noninvasive way, which allows for a patient satisfaction rate of 60% to 100%. Treatment intervention depends on the type of ultrasound platform being used. However, all modalities will require the application of ultrasonic gel that serves as a coupling medium. The US Food and Drug Administration clears MFU-V (Ultherapy System) to lift the soft tissue of the neck, submentum, and brow while improving rhytids on the décolletage. The latest manufacturer guidelines (Ultherapy Amplify protocol) are recommended for the face and neck, which consist of a preset number of pulses per area, using transducers that permit an energy delivery depth range of 1.5 to 4.5 mm. The user can adjust the energy delivered. In the author’s (A.C.) experience, dual-depth (3- and 4.5-mm) transducers provide great versatility, and adjustments to the standard protocol are routinely made to increase pulse number when treating a larger anatomical area or significant laxity. Other adjustments are made when treating the brow, where the 4.5-mm transducer is used to perform two or three times the recommended pulses if the patient has substantial skin thickness and the treatment is tolerated. The pulse number may also decrease when treating smaller areas or cosmetic subunits that are smaller in a specific patient than indicated in the manufacturer guidelines. When treating thinner patients with inadequate visualized depth on ultrasound, the single depth (3 mm) transducer is often used in that select area (most common on the lower neck and brow). Treatment with MFU-V should be avoided over the thyroid gland, thyroid cartilage, trachea, major vessels and nerves, breast tissue or implants, eyes, eyelids, and within the orbital rim.

Another ultrasound device (Sofwave) delivers U/S energy through nonfocused high-frequency Synchronous Ultrasound Parallel Beams (SUPERB) at a depth of 1.5 mm. This U/S device provides significant energy of up to 5 J, when using the facial applicators, which allows for efficient energy delivery to the mid dermis, where there is abundant collagen and elastin, resulting in three-dimensional cylindrical volumetric thermal zones that optimize neocollagenesis and neoelastogenesis. This device has two facial applicators, one with seven transducers (Lift) and another with three transducers (Precise) for areas requiring precision, as well as a third applicator for the body (Lift HD), which can deliver higher energy and density treatments. The facial applicators are moved in parallel, ensuring appropriate coverage of the entire face and neck. Each pulse is 5 seconds with a 1-second interval and an integrated (Sofcool technology) post-cooling time of 1 to 3 seconds, increasing tolerability and allowing for multiple passes. A full-face treatment consists of two passes of approximately 180 to 220 pulses. ^, Tolerability is superior to other ultrasound devices since the energy is delivered above adipose tissue, nerves, muscles, and bone. Therefore, patients often opt to forgo topical anesthetics before treatment. The epidermis is also bypassed with this device, and there is virtually no resulting damage to epidermal structures, which reduces complication rates and improves comfort. ^,

A thorough discussion with each patient regarding postcare instructions is strongly encouraged. After RF therapy, adherence to photoprotection is critical, especially post-RFMN done on individuals with darker Fitzpatrick skin phototypes to minimize the risk of postinflammatory hyperpigmentation (PIH). Thick emollients, zinc-based barrier creams, or serums containing growth factors may also be used post-RFMN to encourage wound healing. Prophylactic topical or oral antibiotics post-RFMN are generally not required. Nevertheless, antiviral prophylaxis may benefit a patient with a significant history of orolabial HSV, especially if treating the perioral region with RFMN. Antiviral prophylaxis is started 3 days before RFMN and continues until complete reepithelialization. Cooling during RF, RFMN, and U/S procedures may increase patient comfort; however, post-treatment cooling is encouraged after MFU-V to reduce the risk of unwanted complications. Similar to treatment with RF and RFMN, photoprotection is still strongly encouraged to avoid unwanted changes in pigmentation, especially in patients with a history of dyschromia.

Strict adherence to the recommended post-treatment care regimen is essential. Patients should be counseled against deviating from this regimen or using any of their topical products on treated areas, as these can increase the risk of irritant, allergic, or granulomatous reactions.

Perioral rhytids and skin laxity of the lower face are common concerns that prompt patients to look into procedures to address these problems. RFMN has been proven to be effective in addressing skin laxity of the lower face ( Figs. 31.1 , 31.2 , and 31.3 ) and the neck ( Figs. 31.4 and 31.5 ) and can also improve perioral rhytids ( Figs. 31.1 and 31.2 ).

Perioral rhytids and lower face skin laxity. Left, before treatment. Right, 1 month after the second session of RFMN on the lower face, performed 1 month after the initial treatment.

(Courtesy Jennifer Segal, MD, with patient consent.)

Perioral rhytids and lower face skin laxity. Left, before treatment. Right, 1 month after the second session of RFMN on the lower face, performed 1 month after the initial treatment.

(Courtesy Jennifer Segal, MD, with patient consent.)

Lower face skin laxity. Left, before treatment. Right, 1 month after the third session of RFMN on the lower face, performed 6 months after the initial treatment.

(Courtesy Jennifer Segal, MD, with patient consent.)

Neck rhytids and skin laxity. Left, before treatment. Right, 1 month after the second session of RFMN on the neck, performed 1 month after the initial treatment.

(Courtesy Jennifer Segal, MD, with patient consent.)

Neck rhytids and skin laxity. Left, before treatment. Right, 1 month after the second session of RFMN on the neck, performed 1 month after the initial treatment. (Courtesy of Jennifer Segal, MD, with patient consent.) U/S modalities treat skin laxity by delivering energy to deeper tissues with MFU-V and targeting superficial layers with SUPERB. MFU-V is commonly used and well-tolerated on the lower face ( Fig. 31.6 ). At the same time, increased tolerability makes SUPERB the frequent treatment of choice for brow ptosis ( Fig. 31.7 ).

Stay updated, free articles. Join our Telegram channel

Join