Master Case Presentation

Journal of Cosmetic Dermatology, 13, 315--323

Comparison of different technologies for noninvasive skin tightening

Rachel N. Pritzker, MD,1 Heather K. Hamilton, MD,1 & Jeffrey S. Dover, MD, FRCPC, FRCP1,2,3,4
1

SkinCare Physicians, Chestnut Hill, MA, USA

Yale University School of Medicine, New Haven, CT, USA
3
Department of Dermatology, Dartmouth Medical School, Hanover, NH, USA
4
Department of Dermatology, Brown Medical School, Providence, RI, USA
2

Summary

Facial skin laxity is a bothersome sign of aging. In the past, the only option for
treating laxity was surgery. While surgical lifting remains the gold standard, there
has been a growing demand among patients for less invasive techniques. Patients are
increasingly seeking procedures with little to no downtime, lower risk profiles, and a
more natural appearance. The industry has responded to these demands with an
emergence of noninvasive skin tightening devices. The rate of development and
marketing of these devices has increased exponentially within the last decade.
Whereas we previously had no options, now we are faced with many choices. How
do we choose which technology is best for our patients? While there is a paucity of
comparative trials to date, a critical exploration of these technologies is worthwhile.
The underlying mechanism of action of all these treatments is essentially the same:
heating of the dermis and subdermal areas while minimizing injury to the epidermis.
In this article, we outline the different technologies and highlight the differences to
help guide us in selecting the right treatment.
Keywords: noninvasive skin tightening, comparison, radiofrequency, intense focused
ultrasound, laser

Radiofrequency
Radiofrequency (RF) based devices produce heating of
the dermis through the application of an electromagnetic current. As electrons shift polarity and move
within the tissue of the applied electrical field, heating
is produced through its encountered tissue resistance
according to Ohms law.1 The depth of heating is
dependent on several factors including the tissues
unique impedance, frequency of the current, cooling
applied, and the type of electrodes.2 Histologically,
irreversible collagen denaturation is seen instanta-

Correspondence: Rachel N. Pritzker, MD, SkinCare Physicians, 1244 Boylston

Street, Chestnut Hill, MA 02467, USA. E-mail: pritzker.rachel@gmail.com
Accepted for publication March 7, 2014

2014 Wiley Periodicals, Inc.

neously even with a single pass of monopolar RF.3 The

subsequent wound remodeling over time then creates
the skin tightening effect that peaks over a 36 month
period. Facial sites treated with a monopolar RF device
showed a significant increase in both type I and type
III collagen 3 months after treatment. Using birefringence examination, there is evidence that this increase
included newly synthesized collagen formation.4
Monopolar radiofrequency

Radiofrequency was the first technology to be studied

and developed for noninvasive skin tightening, and
there has been significant development since (Table 1).
In 2002, the first monopolar RF device (ThermaCool
TC; Thermage Inc., Solta, Haywood, CA, USA) was
approved by the FDA for noninvasive treatment of

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. R. N. Pritzker et al.

Table 1 Current manufactured radiofrequency (RF) devices for facial skin tightening
Product/Manufacturer

Category of Device

Special features

Thermage (Solta Medical)

Monopolar RF

Pelleve (Ellman International Inc.)

Monopolar RF

Exillis (BLT Industries, Inc.)

Monopolar RF

eMatrix, eTwo (Syneron)

Fractionated bipolar RF

!s (Syneron)
elo
ePrime (Syneron)

Bipolar RF + Intense Pulsed Light

Microneedle bipolar RF

Accent (Alma Lasers)

Unipolar RF and Bipolar RF

Venus Freeze (Venus Concept)

EndyMed PRO 3 (EndyMed Medical)

Multipolar RF + Magnetic Pulsed Fields

Multipolar RF

Capacitive coupling technology, multiple size tips for facial and

body treatment
Multiple size tips, continuous motion, facial and body treatment,
surgical electrocautery capability
Constant temperature control on device, depth of penetration
related to amount of cooling, facial and body handpieces
Sublative technology with minimal epidermal injury and wider
dermal heating
Synergistic skin tightening and photorejuvenation
Bipolar electrodes introduced to specific depth through
microneedles
Two handpieces to deliver each type of RF on one platform,
facial and body treatment capacity
Facial and body skin tightening
Real time skin impedance readings, Handpieces for facial and
body sites

periorbital wrinkles and rhytides. This monopolar RF

device produces 3-dimentional volumetric heating as
the current flows from the handpiece to grounding
pad. The initial device dispersed the heat at a controlled depth of 34 mm5 using a unique capacitive
coupling mechanism. The depth and volume of effect
depends on the size and geometry of the device tip.6
The pivotal study to demonstrate this effect was done
by Fitzpatrick et al. After a single treatment on the
forehead and temple, 61.5% of the 86 patients demonstrated an eyebrow lift of at least 0.5 mm on photographic analysis at 6 months post-treatment. Side
effects included erythema (36%), edema (14%), and
epidermal burn (0.4%), all of which were transitory
without long-term sequelae.7 Evidence for the use of
this device on the upper and lower face was subsequently demonstrated, and further FDA approval was
obtained for improvement of facial wrinkles and rhytides in 2004. In an early study of the lower face, 10
of 16 patients found the result to be unsatisfactory.8
However, a subsequent study of 50 patients treated
with the monopolar RF device on the lower face using
a single high fluence pass found significant improvement in cheek and neck laxity in the majority of
patients. Blinded evaluation of photographs 6 months
post-treatment demonstrated a mean clinical improvement score of the nasolabial folds of 1.53, where 1 corresponds to 2550% and 2 corresponds to 5175%
improvement.9 In a split-face comparative trial of treatment vs. no treatment, a mean decrease of 22.6% in
two-dimensional surface area was observed on the
treated side after a single treatment of the jowls of the

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lower face. There were no changes of surface area on

the nontreated side.10
The limitations of this early device were long treatment times, intolerable pain, but most importantly
modest and unpredictable results. Over time, modifications to the RF source, to the delivery tips, and to
treatment protocols, have produced less discomfort,
shorter treatment times, and better results. The treatment protocol was modified based on a pivotal histologic study. Similar collagen effects were seen on
electron microscopy with one high fluence RF pass and
multiple, low fluence RF passes. Furthermore, deeper
effects on collagen were seen with increased numbers
of passes, thus contesting the need for a single, more
painful high energy pulse.3 Clinically, this protocol was
confirmed to produce more predictable outcomes with
a large investigation by a multispecialty consensus
panel. In a survey of 5700 patient treatments, the original treatment algorithm of high energy delivered
over a single pass vs. a new algorithm of lower energy
with multiple passes was compared. At the 6 month
endpoint, 54% of the original algorithm patients vs.
92% of the new algorithm patients noted skin tightening. Additionally, 45% of the high energy, single pass
patients found the procedure too painful compared to
only 5% in the lower energy, multiple pass group.11
Currently this lower-fluence, multiple pass protocol is
the standard of care for this monopolar RF device. Larger tips, which deliver more uniform and deeper
energy delivery, have also been developed to take
advantage of this critical information to optimize
outcomes12 (Figs 1 and 2).

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Figure 1 The evolution of the various treatment handpieces for

the Thermage device. From left to right Thermage Cellulite 3.0,
Thermage Face 3.0 NTX, Thermage Face 3.0 CPT, Thermage
Body 16.0 (orange), Thermage Eye 0.25 (green), Thermage Total
3.0 (orange), and Thermage eye (original tip, not manufactured).
(Courtesy of Solta Inc.).

. R. N. Pritzker et al.

from 7.5 to 20 mm in diameter, allowing for treatment

of both smaller and larger facial areas. Seventeen
patients completed six full face treatments using a
combination of 5 and 10 mm handpieces, selected to
administer both superficial and deep heating. One year
after starting treatments, corresponding to 6 months
after the final treatment, physicians rated a 46% average improvement from baseline photographs and
patients reported a 30% overall improvement of skin
tightening. There was minimal to no associated pain
and no side effects reported.13 A series of treatments
spaced 46 weeks apart are typically performed. An
additional device termed dynamic monopolar RF
(Exilis; BLT, Framingham, MA, USA) also uses a continuous motion technique with an attached temperature sensor and novel cooling system within the
treatment handpiece. The cooling is adjusted to control
the depth of heating as less cooling will allow the heat
to reach deeper into the subcutaneous tissue. Approved
by the FDA in 2009 for the noninvasive treatment of
rhytides, it is commonly used on the face, although
the published data on the use of this device has been
limited to body contouring.
Unipolar radiofrequency

Figure 2 Grid placement for ease of utilizing the multiple pass,

lower fluence per pulse technique (Courtesy of Solta Inc.).

There are other devices using monopolar RF, which

differ in their emission frequency, handpiece, and treatment protocol. A 4-Mhz device (Pelleve; Ellman International, Inc., Oceanside, NY, USA) uses a continuous
motion technique with various size handpieces ranging

2014 Wiley Periodicals, Inc.

Another route of delivering RF to the target tissue is

unipolar RF technology. This is where only one
electrode is present without a grounding pad. An electromagnetic radiation field is emitted in an omnidirectional area around this electrode. Unipolar RF has a
theoretical depth of penetration up to 20 mm, penetrating deep into the subdermal plane, and therefore is
used more frequently for body contouring.14 Unipolar
RF technology can be found in a combination device
with bipolar RF capabilities on the same platform
(Accent, Alma Lasers, Caesarea, Israel). In a split-face
study of 10 patients, each side was treated with either
the unipolar or bipolar modality. Both sides did not
show significant improvement in skin tightening after
four weekly treatments.14 Yet in another study of the
same device, using both the unipolar and bipolar settings over four to six treatments, a majority of patients
were rated on photographic analysis as having
5175% improvement of the cheeks and jowls.15
Bipolar radiofrequency

Since the introduction of monopolar RF technology,

many variations of RF have emerged for skin tightening. In bipolar RF, the current runs between the two
electrodes on the treatment tip and a grounding pad is

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. R. N. Pritzker et al.

not needed. The advantage over monopolar RF is a

controlled, predictable depth of heating, but this depth
is more superficial as it is restricted to half the distance
between the two electrodes. This depth usually corresponds to 24 mm within the dermis.14
Bipolar RF devices are frequently combined with
other optical energy sources, such as intense pulsed
light (IPL) or a 900 nm diode laser, for potentially
synergistic effects. The optical energy heats the dermis, lowering the tissue impedance, theoretically
enhancing the effects of the RF energy.6 Studies of
this combined technology rarely specifically evaluate
the effect on skin laxity, but rather rhytides and skin
texture. A prospective study using a combination
900 nm diode laser and bipolar RF device (Polaris
WR, Syneron, Yokneam, Israel) for treatment of rhytides found that more than half of the 23 subjects
demonstrated >50% improvement in wrinkles after
three treatments.16 A large, uncontrolled study of 108
patients treated with a combination IPL and bipolar
RF device (Aurora SR, Syneron, Yokneam, Israel)
showed overall skin improvement and improvement in
skin laxity of 75.3% and 62.9%, respectively, on double-blinded physician photographic evaluation.17 The
above mentioned devices are not currently in manufacturing, but the new marketed device (elos Plus;
Syneron, Irvine, CA, USA) has the bipolar RF, diode
and IPL combination on a single platform, with each
unique handpiece having a combination of two of
these energy sources.
Bipolar RF has also been combined with a vacuum
system, and these devices are termed functional aspiration controlled electro thermal stimulation (FACES).
The vacuum brings the target tissue closer to the
applied current, thereby maximizing depth of penetration over bipolar RF alone. In a study of this
technology, 46 participants had eight treatments
(Aluma; Lumenis, Santa Clara, CA, USA; no longer
manufactured) and were evaluated using the Fitzpatrick-Goldman Classification of Wrinkling and Degree
of Elastosis Scale. The subjects mean score improvement corresponded to a reduction of full wrinkle
class on this scale at 6 months post-treatment.18
Interestingly, the original investigation of monopolar
RF applied to periorbital region using the high fluence, single pass algorthim was also measured on
this scale. At 6-month follow-up, 29% of the monopolar RF subjects experienced at least one unit of
improvement on the Elastosis Scale; 85% of the bipolar RF combined with vacuum subjects experienced
equivalent results.7

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Fractional radiofrequency

Fractional RF technology is another form of RF treatment. It can be delivered by using a fractionating tip
on the skin surface or by using an array of needles
inserted into the skin. While RF devices generally do
not affect the epidermis, these new devices deliver the
bipolar RF energy through microchannels, utilizing the
same principles of cutaneous healing as nonablative
fractional resurfacing lasers.
Certain devices use treatment tips with parallel rows
of bipolar electrode pins to create closed circuits
amongst these pins (Fig. 3). The density of pins and
emitted energy control the depth and amount of ablation. The multiple electrodes create many pyramidal
shaped zones of injury resulting in a small amount of
epidermal disruption overlying a wider area of heating
in the deeper tissue. Demarcated zones of ablation and
coagulation on human abdominal skin ranged from
100 to 450 lm in depth (Matrix RF/eMatrix, Syneron).19 The 44 and 64 electrode density tips created
deeper thermal effects histologically and greater
improvement in rhytides clinically compared to the
144 electrode tip which showed epidermal disruption
and greater effect on superficial photodamage.20 In
terms of efficacy for skin tightening, after three
monthly treatments (Matrix RF/eMatrix, Syneron) in
36 patients, an improvement of 40% or greater in skin
tightening was found in 55% of patients, yet no statistically significant decrease in wrinkling and elastosis
scores were found. No side effects or significant downtime was reported.19

Figure 3 Fractionated radiofrequency; an example of the eMatrix

treatment tip demonstrating the electrodes and the flow of energy
(Courtesy of Syneron/Candela).

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Comparison of Technologies for Skin Tightening

A different bipolar fractional RF device uses microneedles as a delivery system. The microneedles insert into
the reticular dermis, arranged in pairs, and bipolar RF
energy is delivered between them. Histologically, it has
been shown to induce a vigorous wound healing process, neocollagenesis, and neoelastogenesis (Renesis, Primaeva Medical Inc., Pleasanton, CA, USA).21 In a
randomized, blinded, quantitative study, the microneedle fractional RF device (Miratone, Primaeva Medical
Inc.) resulted in a 16% improvement in skin laxity on
the face.22 In a recent, prospective, split-face comparative study of 12 healthy women, botulinum toxin A
injections resulted in better improvement in periorbital
rejuvenation at 1 month but microneedle fractional RF
was superior at 3 months. Hyperpigmentation on the
microneedle fractional RF side was reported in two
patients, which resolved spontaneously within
2 months.23The Renesis and Miratone device are now
more commonly known as the ePrime device (Syneron).
A prospective study of 10 patients undergoing one treatment of 110-130 insertions per side (ePrime, Syneron)
on the lower face demonstrated lifting with 3D imaging.
Clinical assessment noted reduction of the jowls and elevation of the malar prominence. Three dimensional
imaging documented an increase in volume of the face
and an elevation of 1.79 mm at 4 months.24
Multipolar radiofrequency

Lastly, a device that uses multipolar radiofrequency in

combination with pulsed electromagnetic fields (Venus
Freeze; Venus Concept, Karmiel, Israel) has been
shown to affect facial skin tightening. After a series of
10 treatments, 30 of 31 patients were rated by blinded
physicians as having at least a 1 grade improvement
in the Fitzpatrick Wrinkle and Elastosis Scale 3 months
after the last treatment. All treatments were rated as
pain free using a visual analog scale.25 A similar
device which utilizes multisource radiofrequency
(EndyMed Pro, EndyMed Ltd, Cesarea, Israel) has the
ability to monitor real-time skin impedance measurements during treatment. This device also has multiple
treatment handpieces for face and body contouring,
including one to perform fractional skin resurfacing.

Infrared devices
Skin tightening has also been demonstrated with infrared light devices and lasers. Wavelengths in the infrared spectrum are absorbed by water in the skin
causing dermal heating. For example, a device with a
wavelength range from 1100 to 1800 nm was found

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. R. N. Pritzker et al.

to cause immediate skin tightening with effects lasting

up to 12 months in 22 of 25 patients using fluences
ranging from 20 to 40 J/cm2. (Titan; Cutera, Inc., Brisbane, CA, USA) Treatments were well tolerated without the use of anesthesia. Three patients had small,
superficial, second-degree burns that healed uneventfully. Subset analysis demonstrated that better results
were achieved with a fluence of 30 J/cm2 and 150
360 pulses when compared to a fluence of 2025 J/
cm2 and <150 pulses.26 Tightening was also found in
older individuals27 and in an Asian population.28 In
both these latter studies, treatment was performed
twice, 1 month apart. Among lasers studied for their
tightening effects, a 1450-nm diode (SmoothBeam,
Candela Corporation, Wayland, MA, USA) was shown
to lead to modest improvements in rhytides: 15% of
patients had moderate improvement, 50% had mild
improvement, and 35% had no obvious change.29 In
addition, treatment with a 1320 nm neodymiumdoped yttrium aluminum garnet (Nd:YAG) laser (New
Star model 130 Nd:YAG laser; New Star Lasers,
Auburn, CA, USA) has been shown to improve severe
rhytides.30 Combination wavelength techniques have
also been investigated. After 3-6 treatments of combination of long pulsed 532-nm potassium titanyl phosphate (KTP) laser (Aura laser; Laserscope, San Jose,
CA, USA) and long pulsed 1064- Nd:YAG laser (Lyra
laser; Laserscope), patients were found to have a
4060% improvement in skin tone/tightening.31

Laser resurfacing
Laser resurfacing has also been found to induce skin
tightening. The more heat delivered by the device, the
more likely it is to tighten skin. While nonablative
devices for the most part induce little or no tightening
of skin, ablative devices, especially CO2 lasers, are more
likely to tighten skin.3234 Fractional devices are less
likely to do so compared with nonfractional ones.
While the authors acknowledge the invasive nature of
ablative resurfacing, we find it important to report its
effects in regards to skin tightening while reviewing
the literature and comparing available technologies.
Nonfractional carbon dioxide (CO2) (UltraPulse CO2
laser; Coherent Medical Group, Santa Clara, CA, USA)
and erbium lasers (Derma K; ESC Medical Systems,
Needham, MA, USA) were reported to induce an average of 43% and 42% tightening, respectively, which
gradually diminished to 34% and 36% by 6 months.32
Due to the unfavorable side effect profile of the traditional CO2 and erbium lasers, fractionated CO2 laser
technology was explored for its role in skin smoothing

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. R. N. Pritzker et al.

and tightening. Several recent studies have reported

tightening with ablative fractional photothermolysis.
Tierney et al. demonstrated 65.3% mean improvement
in lower eyelid skin laxity with a series of 23 fractional CO2 laser treatments (SmartXide Dermal Optical
Thermolysis (DOT laser); Eclipse Med, Dallas, TX,
USA).33 In another study of periorbital skin, all
patients showed global improvement in eyelid skin
tightening with 11.1% demonstrating excellent
improvement, 24.5% marked improvement, and 33.3%
moderate improvement (SmartXide DOT; DEKAM.E.L.A., Calenzano, Italy).34 Nonablative fractional
photothermolysis has also been investigated for its role
in skin tightening and has been found to induce facial
skin tightening.35 In one study, all patients treated
with a 1550-nm erbium-doped fiber laser (Fraxel 750
SR laser; Reliant Technologies Inc., Mountain View,
CA, USA) on 37 occasions experienced some degree
of eyelid tightening: 28% achieved 125% improvement, 26.9% achieved 2550%, 25.8% achieved
5075%, and 19.4% achieved 75100%.36 In an animal model, however, the skin tightening effects of nonablative and ablative fractional lasers were compared,
and the ablative fractional laser (10 600 nm eCO2!;
Lutronics Co., Gyeonggi-do, Korea) was found to
induce significantly more skin tightening than the
nonablative fractional laser (1550 nm Mosaic!;
Lutronics Co., Gyeonggi-do, Korea).37

Ultrasound
Intense focused ultrasound energy tightens skin by
delivering thermal energy to the dermis and subcutis.
Zones of coagulation are produced within the highly
focused beam from the absorption of this acoustic
energy within the tissue. From porcine soft tissue and
postmortem human skin examinations, the focused
beam delivered in milliseconds is configured to produce
zones of coagulative necrosis approximately 1 mm3 in
diameter or smaller. The depth and volume of these
zones are determined by the preset focus depth, frequency, and energy delivered by a given probe.38
The FDA approved device (Ulthera, Ulthera Inc.,
Meza, AZ, USA) contains several probes of different frequencies with the higher frequency probes producing a
more superficial tissue effect. This ultrasound device
was initially FDA approved in 2009 for noninvasive
eyebrow lift. While treating the forehead, temples,
cheeks, submental, and lateral neck areas with various
probes, Alam et al., demonstrated objective eyebrow
elevation. From 35 subjects, comparing measurements
from fixed landmarks on photographs, a mean average

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change in eyebrow height was 1.7 mm at 90 days

postprocedure. From blinded physician evaluation of
paired photographs, 30/35 (86%) were observed to
have clinically significant improvement of eyebrow
position. Pain scores were on average 3-4 on a 10point scale, but five subjects reported a pain score >7.
There were no serious adverse events.39
In 2012, the FDA approved this same ultrasound
device for skin lifting of the neck and submental area.
Lee et al. applied two passes, a single pass of each the
4-MHz, 4.5 mm probe and the 7-MHz 3.0 mm probe
to the face and neck. Blinded evaluators of photographs comparing baseline and 90 days post-treatment
demonstrated 8 of 10 subjects with clinical improvement, 50% with moderate improvement. Mean pain
was rated at 3.9 out of 10.40
The tissue response from these thermal coagulative
changes is similar to other heating devices such as radiofrequency and ablative resurfacing, but differs in
that the heat is only directed within the intense,
focused beam and not in a volumetric manner. This
creates similar histologic changes to fractional nonablative devices, but its advantage is complete sparing of
epidermal injury.41 Intense focused ultrasound is able
to cause collagen denaturation within the superficial
musculo-aponeutroic system (SMAS) which leads to
tissue tightening on a deeper plane then the other
types of devices.41 Clinical results of tightening from
specifically heating the SMAS with this device have
not yet been reported, but could theoretically product
an enhanced tightening effect over other technologies
unable to target the SMAS.
Variation in pain reported during treatments with
this device has ranged from as little as all patients
reporting minimal pain42 to studies where 14% of
patients reporting pain greater than seven on a 10point scale.39 Some physicians choose to pretreat
patients with oral anxiolytics and oral or intramuscular narcotic analgesic.43 Recent upgrades to the software (AMPLIFY software; Ulthera Inc.) made in
October 2012 have improved patient comfort and have
reportedly reduced pain. (M. Likens, Ulthera, personal
communication, May 9 2013) These changes include
the utilization of lower energy levels and multiple
passes, not dissimilar to the changes adopted by the
monopolar RF (Thermacool TC) device earlier.

Comparison studies
Studies which directly compare noninvasive technologies for skin tightening are rare. Only three comparative studies were found in the literature to date, two of

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Comparison of Technologies for Skin Tightening

which compare the same devices. Key evaluated 12

patients in a split-face study of monopolar RF (ThermaCool TC, Thermage, Inc.) vs. long-pulsed 1064 nm Nd:
YAG laser (Gentle YAG, Candela Corporation, Wayland, MA, USA). Each patient received one treatment
with the low-fluence, multipass technique of monopolar RF to a single side and one treatment with multipass technique, long-pulsed (50 ms) 1064 nm laser to
the other. From photographic comparison, an improvement was noted on the lower face for each device, but
there was not a statically significant difference between
the two sides. In an overall enhancement rating, the
laser side was significantly improved over the RF. Both
treatments did not have any downtime or side effects
noted.44 In the other split-face, comparison study of
these same two devices, photographic comparison
found greater improvement for wrinkles and laxity on
the laser treated side.45 Between these two studies, the
number of pulses of RF applied and the energy of the
laser differed, making comparison between them difficult.
Comparing unipolar vs. bipolar RF, a spilt-face trial
using a device with a handpiece for each technology
(Accent, Alma Lasers, Caesarea, Israel) was performed.
Ten patients randomized to receive a treatment on one
side of the face with unipolar RF and the contralateral
sides treated with bipolar RF were evaluated. Neither
side achieved a statistically significant clinical improvement, but both trended toward improvement. There
were no differences in pain or side effects between the
sides.14
Lastly, in a valuable evaluation, Alexiades-Armenakas et al. compared mirconeedle bipolar fractional radiofrequency (FRF) (Miratone, Primavea Medical Inc,
Pleasonton, CA; now the ePrime, Syneron, Irvine, CA)
with surgical face lifting, the gold standard for skin
tightening. Fifteen patients underwent one treatment
of the lateral mid and lower face with a FRF device
and five patients received a surgical face-lift. Photographs of 21 patients from baseline and 6 months
post-treatment were analyzed using a validated skin
laxity scale by blinded, nontreating physicians. The
analysis demonstrated a mean 1.20 grade improvement for the surgical procedure vs. a mean 0.44 grade
improvement for the noninvasive modality. This corresponds to a 49% improvement from baseline for a surgical face-lift and a 16% improvement for FRF
treatment, the difference between the two treatments
being 37%.23 This comparison highlights the finding
that noninvasive modalities do not produce the same
extent of skin tightening as surgical intervention but
still demonstrate a modest effect, and this difference

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. R. N. Pritzker et al.

has now been quantitatively demonstrated. This is

important for preprocedure guidance of patient expectations.

Conclusions
As technologies continue to emerge to meet the growing demand for noninvasive skin tightening, the data
supporting many devices continues to accumulate at a
rapid speed. It has been shown, in one setting or
another, that all of these devices are effective. They all
produce some degree of skin tightening and demonstrate the histologic alterations to create these changes.
They all have little to no downtime and a low-risk, side
effect profile. Yet, the major question now arises: how
do we compare these devices for predictable patient
outcomes?
The comparison of these new technologies is difficult
due to many factors. First, when comparing individual
studies of the various technologies, the methods of
data collection vary from study to study. These methods range from nonstandardized photography to computer-generated measurements from fixed landmarks.
Second, the clinical endpoints evaluated differ among
the studies. Whereas some focus on the impact on
skin laxity, some measure wrinkle reduction, some
evaluate acne scarring improvement, while others
measure overall skin rejuvenation. Lastly, the scales
for measuring specifically skin laxity are often subjective and diverse, making it inherently difficult to compare results. Difficulty lies in quantifying skin
tightening on the lower face, as there are no fixed
landmarks from which to measure changes as exist in
the upper face. Scales to quantify the changes seen
with skin tightening need be uniform and standardized amongst studies to successfully compare effectiveness.
It is also important to note the improvements to
treatment protocols and devices made throughout the
years when attempting to compare devices. These
changes are made to attempt to have better and more
predicable outcomes and an improved patient experience. Therefore, earlier investigations of devices may
not be able to be compared to more recent studies.
What we really need in this growing aspect of our
field is controlled, comparison studies utilizing standardized scales. However, it is unlikely that such comparison studies will be performed because the
companies have little incentive to initiate these side-byside comparisons due to the high cost but more importantly the concerns of a negative outcome for their
device.

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Overall, the effects of noninvasive skin tightening are

modest at best but appear to be long lasting. These
technologies all work, but patient selection is paramount. In the opinion of the authors, the ideal candidate has little laxity, but patients with more severe
laxity should not necessarily be excluded as they too
are seeking less downtime and minimal risk. Engaging
patients in full discussion about the usefulness of these
technologies and managing expectations is crucial for
patient satisfaction.

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