In the search for ways to draw more patients into the office and offer more services to existing patients, ophthalmologists often consider offering procedures that would fall outside standard ophthalmic treatment. One service that can be performed in-office and will appeal to many ophthalmic patients is tightening of the skin on the face and neck. Dozens of devices that can accomplish this are available; all of them cause skin tightening by generating heat through or under the skin, causing damage at the cellular level. The healing that follows tightens the epidermis and underlying layers—sometimes including muscle, if used for something like a brow lift—and also causes the remodeling of collagen and elastin, further tightening the skin.
Fractionated CO2 laser treatment around the eyes, before (left), immediately afterwards (center) and at five days postop (right). The thermal damage caused by the laser results in remodeling of collagen and elastin, tightening the skin.

Jason D. Bloom, MD, is director of facial plastic and reconstructive surgery at the Main Line Center for Laser Surgery, which offers many nonsurgical skin-tightening procedures; the Center has participated in clinical trials of many of the devices currently used in the industry. Here, Dr. Bloom explains the basic options that are currently available and offers advice to any ophthalmologists considering offering one or more of these services.

Five Approaches

Dr. Bloom says he finds it helpful to divide today’s nonsurgical skin-tightening technologies into five categories:

Fractionated laser. “The first gold-standard technology used for facial skin tightening was the CO2 laser, using unfractionated laser energy,” Dr. Bloom says. “Very few people use that now. It produces a significant amount of skin tightening, but it comes with a very high risk of scarring and hypopigmentation; patients have two weeks of downtime and three to six months of being red like a tomato.

“Since then, the laser energy has been modified for fractionated delivery,” he continues. “Unfractionated delivery creates something akin to scorched earth, while fractionated delivery creates a tiny checkerboard pattern of injury. Thus, lasered skin is next to unlasered; the undamaged tissue grows over the damaged tissue, and the area heals in about one- third of the time. Patients put on ointments for a couple of days, but by day five women are able to wear makeup again; then they’re a little pink for another week. Systems designed for this purpose include the ResurFX module of Lumenis’s M22 system, the Fraxel Repair and the Pixel CO2 System. Other fractional ablative lasers use different light sources; some, such as erbium-based lasers, cause less thermal damage and leave the patient less red. The tradeoff is usually that they require a greater number of treatments to achieve the desired effect.”
Fractionated laser around the mouth, before (left) and after treatment (right).

Radio frequency energy. Devices in this category use radio frequency energy to generate heat transcutaneously. “Radio waves penetrate deep into the subcutaneous tissues,” Dr. Bloom explains. “The heat stimulates production of collagen and elastin, which tightens down tissue over time. However, these devices tend to use lower energy levels and require multiple passes to create the desired effect. Devices in this category include Thermage CPT (Valeant), Exilis Protégé Elite (BTL), ThermiSmooth (Thermi) and Pelleve (Cynosure).”

Microfocused ultrasound. Dr. Bloom says this third category is still noninvasive, but reaches a deeper tissue layer. “Ultrasound normally is nonspecific; it penetrates deeply but causes no lesions,” says Dr. Bloom. “This technology focuses the energy, like a child using a magnifying glass to focus sunlight on an ant. You lay down lines of these subsurface microinjuries, causing contraction and remodeling of collagen and elastin. Using this technology, it can take three to six months to see the results. Ulthera is the only company with a product in this category; it’s approved for brow-lifting and treating the lower face, neck and décolletage area. It does produce a fair amount of skin and soft-tissue tightening.”

Radio frequency microneedling. Dr. Bloom explains that these devices deliver the energy through the epidermis via tiny needles that pierce the skin. “Some of these devices have 150 needles; some have 24; some have 60; some use paired needle sets,” he says. “Some use needles that are coated with insulation so the energy comes out only at the tip, while others are not insulated, so the energy causes damage along the entire needle track. More damage means more effect, but also more downtime; the latter patients can ooze a little bit because you’re causing an injury all the way up through the epidermis. I only use the coated needles. Devices in this category include Infini (Lutronic), Profound (Syneron Candela), Fractora (InMode) and Intensif RF Microneedle (EndyMed).”

Cannulated delivery under the skin. Dr. Bloom says the newest frontier involves using a stiff, insulated 18-ga. cannula that’s inserted through a tiny hole in the skin and moved around by the surgeon. The cannula may deliver radio frequency or laser energy, depending on the system. “This approach is great for tightening the neck, but it’s sometimes used in the face as well,” he explains. “To treat the jowls and neck, I make three small openings with 16-ga. needles following tumescent anesthesia—one opening under the chin and one under each earlobe. I run the cannula back and forth under the surface of the skin in a fan pattern, above the muscle, just underneath the subcutaneous fat. I still consider this nonsurgical, because there’s no trip to the OR and no sedation or general anesthesia; I tell the patients that I don’t use any scalpels or sutures. This procedure takes about an hour and a half, with results that resemble a surgical facelift. (See photos, facing page.) It involves a little more surgical downtime, but most patients have it done on Wednesday or Thursday and are back at work on Monday. Devices in this category include ThermiTight (Thermi), PrecisionTx (Cynosure) and FaceTite/NeckTite (InMode).
Cannulated delivery of energy through tiny holes in the skin—done in-office using tumescent anesthesia—can produce results resembling a surgical face or neck lift.

Dr. Bloom says most of these procedures have a very short learning curve. “The one exception might be the last category of devices, which use a cannula,” he says. “To use those you have to be familiar with tumescent anesthesia, and they take a couple of cases to get used to. But most of these procedures can be learned by almost anyone. In fact, that’s a problem, because laws regulating these procedures differ from state to state. In some states, anyone can operate the equipment and perform procedures. As a tertiary site, we sometimes see patients who have been badly burned or disfigured by non-surgeon procedures. Meanwhile, in other states, only a doctor is allowed to perform these procedures.”

Tips for Success

Dr. Bloom—who notes that he has learned a lot about lasers from working with Eric Bernstein, MD, a dermatologic laser surgeon—offers these tips to any ophthalmologist considering adding one of these devices/procedures to your practice offerings:

Check the regulations affecting use of these devices in your state before purchasing one—especially if you won’t be the person operating the device. As noted, laws vary widely from state to state. “Make sure you’re clear about the legal ramifications of offering these services before you begin,” says Dr. Bloom.

Never take advice on settings from the manufacturer’s rep. “The rep will often tell you to turn the energy level up very high to get quick results,” notes Dr. Bloom. “That’s usually bad advice. Before I operate a new device I talk to colleagues who are familiar with it to get their advice on settings, patient selection and so forth.”

Consider taking a course on the procedure. “The American Society for Laser Medicine & Surgery provides excellent courses on the use of these technologies,” says Dr. Bloom. “They have an annual meeting in April and offer regional courses as well. I lead a course on periorbital therapies using these devices. You can find information at”

When a rep brings in a new device, try it out on the rep. “This can be a good way to make sure the device is safe,” Dr. Bloom notes.

It might be worth offering more than one option. “One size does not fit all,” says Dr. Bloom. “Patients want different results, have different tolerance for downtime, different financial situations, different tolerance for invasiveness, different pain tolerance and different ideas about how long they’re willing to wait before seeing results. If you can offer more than one option, you’ll get more patients interested.”

Don’t try to use one device to do everything. “You can’t use one device to do everything, or use the same device on every patient,” says Dr. Bloom. “For example, some lasers work better on light or dark skin. These devices aren’t cheap; they range from $45,000 to $100,000 or more. On the other hand, some of these devices, such as a CO2 laser, can be used for multiple purposes. If you’re going to invest in a single device, think carefully about what your patients are likely to be interested in, and do your homework before purchasing.”  

Dr. Bloom serves as a trainer, consultant or speaker for many of the companies mentioned, as well as many others across the laser and aesthetics industry.  REVIEW