Surgical vs. Nonsurgical Skin Tightening

Mark Hamilton, MD, a facial plastic surgeon in Indianapolis, Ind., says he and others in his specialty bring a critical eye to the results that nonsurgical technologies deliver.

“If someone says ‘facelift-like results,’ we expect to see something in that category, or at least close to it,” he says.

While devices enter the market with big claims and good studies, Dr. Hamilton says in his experience these devices aren’t quite as good as they appear to be. The question becomes, how do they fit into the plastic surgery practice?

In his presentation, “Non-Surgical Skin Rejuvenation: How Good are We Really?,” at the 2020 virtual meeting of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), Dr. Hamilton discusses realistic expectations with nonsurgical skin rejuvenation technologies, patient demand, and appropriate use.

“We know the gold standard for treating skin laxity is surgical excision. We know we can get excellent results with facelifting techniques in both young [and] older patients [and in] challenging situations. And even patients who are on the younger side for facelift procedures—who maybe in the past I would shy away from [with] these procedures—with today's sculpting techniques and patients more open to doing these treatments at a younger age, you can really get some excellent results,” says Dr. Hamilton.

But the reality is, patients want nonsurgical options.

“Minimally invasive procedures are growing at twice the rate of surgical procedures,” he says.

And as a result, surgeons also need to offer nonsurgical skin tightening options. Deciding what is right for your practice is where the legwork comes in and what Dr. Hamilton aimed to tease apart in his presentation. He divides the available skin tightening devices into three categories: external, microneedling, and percutaneous.

External Devices

External devices (laser, ultrasound, radiofrequency [RF]) offer the benefits of comfort and no downtime.

“I think the advantage of having a painless, no-downtime option is important,” says Dr. Hamilton.

The challenge with external devices, he says, is that the threshold for an epidural burn is 48°F, but thermal collagen contraction and remodeling takes place at 55°F to 80°F.

“Multiple sessions are required, but as with many of these external devices, there's high patient satisfaction,” he says.

While patients may be happy with subtle results, the plastic surgeon’s eye is more critical.

“I would caution you as you look at these devices, and some of these that will claim excellent results, always look at photography, lighting, head position. When we're dealing with such subtle improvements, these can really dramatically affect things, and we all struggle with it.”

Microneedling

According to Dr. Hamilton, the second nonsurgical skin tightening category, microneedling, offers an advance in nonsurgical skin tightening.

“With microneedling you’re allowed to place the energy directly into the dermis where you want it to be. There's less risk of epidermal injury because you’re using insulated tips,” he says.

And it’s safe for all skin types.

Of those available, “We were attracted to the Profound device, because of so many studies, and one study in particular… had the conclusion that fractional RF with their device provided 37% of the result of a facelift,” says Dr. Hamilton. “As a facial plastic surgeon, I was very excited about those numbers in such a study.”¹

However, in his practice, they never achieved the quantified results described in the study. Dr. Hamilton also says that microneedling isn’t without its own challenges, pointing out that it’s painful, time consuming, technically challenging, and includes some downtime. He describes a post-treatment patient with dermal atrophy, which, he admits, may have been operator error. Fortunately, the issue resolved over time.

All things considered, “I do believe microneedling is a step forward from external skin devices,” says Dr. Hamilton. “Most patients, I can say, did feel like their skin had improvement in terms of texture. But unfortunately, in terms of skin tightening, results remained really very subtle and unpredictable.”

Next: Percutaneous Skin Tightening