We all have one priority with all of our facial rejuvenation patients: Having happy, satisfied patients. With this in mind, I find I am torn by the armamentarium of noninvasive tightening devices to choose from. What are the critical factors in choosing a platform for your practice? Most practices look at pain, downtime, cost, and the number of treatments necessary to reach the expected outcome.

Am I alone, or is everyone else also perplexed when six to eight treatments with a device are required for visible results? Very few of my patients agree to come in for a procedure six to eight times, and if multiple treatments are needed, patients get frustrated with the time commitment and cost. Prioritizing patient satisfaction should be a cornerstone in choosing the interventions we perform.

Tissue tightening is an excellent in-office procedure for skin laxity and mild photoaging. The treatment options are varied and include radio-frequency, ultrasound, and fractional resurfacing. There are numerous devices on the market that deliver energy into the dermis thereby causing collagen contraction and neocollagenesis. In my experience, the more “invasive” procedures or surgical tissue-tightening procedures provide the most reliable and immediate results. The radio-frequency and ultrasound devices that are “noninvasive” have little down-time, but multiple treatments are often needed and have inconsistent outcomes.

The technology for noninvasive modalities has improved over the last decade, but there are still no longterm clinical data, and results are highly varied. The difference in protocols and outcomes depends on proper patient selection, method of energy delivery, and sequential treatments.

As long as patients have realistic expectations and patients are correctly selected, patients can be happy with any of the aforementioned procedures. For some radio-frequency and high-focused ultrasound energy devices, only one or two treatments may be needed, but the results occur over a period of 6 months, which can be a long time for patients to notice the changes because they see themselves every day. Thus, baseline photographs and photographs at regular intervals (1 month, 3 months, 6 months) can help reveal the change (or lack of change).

We believe the optimal way to utilize these devices is as a combination approach with other procedures to optimize skin tightening and improvement in tone and texture. Tissue-tightening devices should be used with fractional ablative or nonablative resurfacing, fillers, and toxins. Often, we recommend starting with fillers and resurfacing treatments first to get the immediate “wow” factor and achieve immediate patient satisfaction. If patients want to then add skin tightening, this can be useful as an adjunct treatment and can even be used as a maintenance approach once per year. Actinic damage is also highly predictive of the degree of tissue laxity. Treating both the dermis and epidermis together delivers more immediate results. Using a fractional resurfacing device provides tissue tightening, improved skin color, decreased discoloration, and a reduction in the number of brown spots and freckles. Patients usually only need one to two treatments, there is minimal downtime, and satisfaction is very high.

The most limiting factor however, is cost – for both the provider and the patient. The fixed and disposable costs of radio-frequency and ultrasound devices are high, whichtranslates into high patient costs as well. Treatments are also very time consuming, and about 20%-30% of patients don’t notice any difference at all. Setting realistic expectations is imperative, and combination treatments are necessary.

In my practice, I choose fractional resurfacing treatments first. If patients want additional tissue tightening, radio-frequency is used as an adjunct treatment. This keeps costs lower, patients happier, and results more attainable.

When choosing devices for my practice, I follow a simple mantra: highest satisfaction per patient dollar spent. Happy patients build trust and integrity for the provider and practice. Don’t just buy a device because others are using it, and don’t just recommend a device because you have it.

Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They have no relevant disclosures.


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