Advanced Skin Tightening Technologies Gaining Momentum Over Botox & Fillers

What is Botox?
Botox, short for Botulinum toxin, is a commonly used substance in anti-aging treatment that isa neurotoxic protein produced by the bacterium Clostridium botulinum. It is widely known for its cosmetic applications in reducing the appearance of wrinkles & fine lines. What way Botox works is through blocking the release of a neurotransmitter called acetylcholine, which is responsible for muscle contractions. When injected into target muscles, it renders them temporarily paralyzed. The paralyzed muscles are unable to contract, thus lessening the chance that wrinkles would form. This process helps to smooth out the skin and give it a more youthful appearance. Botox is a purified and safe form of the toxin when used in controlled medical settings.

How Botox Works to Stop Wrinkles
The mode of action of Botox involves its interaction with the neuromuscular junction, where nerves meet muscles. Botox binds to presynaptic nerve terminals and prevents the release of acetylcholine, a neurotransmitter that transmits signals from nerves to muscles. By inhibiting acetylcholine release, Botox effectively interrupts the communication between nerves and muscles, resulting in the temporary muscle paralysis. The effects of Botox injections typically become noticeable within a few days to a week and can last for several months, after which the body gradually metabolizes the toxin, and muscle function returns to normal. As normal function resumes, so do the wrinkles, at which point most users, if interested in continuing to enjoy the aesthetic benefit offered by Botox, would want to schedule a ‘top up’ session to have additional units of Botox injected into desired target areas again.

Original Use Case of Botox & FDA Approval
A little known fact about Botox is that it was initially approved by the U.S. Food and Drug Administration (FDA) for therapeutic purposes to treat medical conditions such as muscle spasms and excessive sweating. However, over time, its cosmetic benefits became well understood, leading to its widespread ‘off label’ use in cosmetic procedures. It must therefore be noted that, in rare instances, the use of Botox can result in potential side effects, such as temporary muscle weakness or drooping, localized pain, and rare allergic reactions. Thus, it is highly advisable for an individual to consult with a healthcare provider or licensed medical practitioner to determine their suitability for using Botox, and to ensure that it is administered safely and effectively.

Alternatives to Botox and Fillers

Laser Skin Tightening
Laser skin tightening is a noninvasive cosmetic procedure, often limited to being offered by cosmetic clinics and spas, which uses rays of specific laser energy to stimulate collagen production and improve skin elasticity. Operating using targeted wavelengths of light, which could take the form of fractional laser beams or infrared light, it channels light energy into specific skin depths, which generates controlled heat, resulting in the stimulation of collagen. It also remodels and contracts collagen, much like how other technologies such as RF and Ultrasound, that will be discussed in this article, also do. This process triggers the production of new collagen & elastin fibers, leading to tighter and firmer skin over time. The procedure is popular and common at cosmetic clinics given that it is well-tolerated, and given that the treatment can work for a range of skin types since the intensity of the laser can be adjusted based on individual needs, skin types, concerns and comfort. However, often a single treatment is insufficient, and often multiple treatment sessions will be necessary to achieve desired anti-aging results.

The Scientific Literature on Laser Skin Tightening:

• Alexiades-Armenakas et al. (2008): This review article provided an overview of various laser technologies used for skin tightening. It concluded that laser skin tightening can effectively improve skin laxity and stimulate collagen production. The article highlighted the positive clinical outcomes and discussed the mechanisms of action for different laser modalities.
• Weiss et al. (2011): This article focused on the combination of laser technologies, including infrared lasers, for rejuvenating the aging neck. The study found that laser skin tightening was effective in addressing neck laxity and achieving comprehensive rejuvenation results. The combination of technologies yielded successful outcomes in improving the appearance of the aging neck.

Radiofrequency Skin Tightening
Similar to laser skin tightening, Radiofrequency (RF) skin tightening is also a popular noninvasive cosmetic procedure that utilizes EM waves (in the radiofrequency range) to tighten and rejuvenate the skin. Just as is the case with laser treatments, RF treatments also work by delivering controlled heat energy to the deeper layers of the skin, stimulating collagen production and remodeling in the process, however, with the key difference being that RF waves instead of laser light is being used. The radiofrequency waves penetrate the skin, causing gentle heating of the underlying tissues, which triggers a wound healing response. This process promotes the production of new collagen fibers, leading to improved skin elasticity, reduced laxity and an overall reduction in the appearance of wrinkles, fine lines and sagging.

Similar to the variance in intensity that can be controlled in a laser skin tightening treatment, RF intensity can also be similarly modulated and guided across the treatment area in a controlled manner. The RF treatment is als usually well-tolerated by most individuals, however, the one advantage it enjoys over laser skin tightening is that RF can be used for almost all skin colors and types, whereas lasers do operate hotter than RF, penetrating through the epidermis, whereas the RF’s impedance characteristics make it more ‘active’ and ‘operational’ - in heat terms - more specifically in the relevant regions, i.e., the dermis layer of the skin that most skin tightening treatments target for stimulation.

Scientific Findings: Radiofrequency Skin Tightening

• Manuskiatti et al. (2005): This study assessed the efficacy and safety of a microablative radiofrequency device for skin rejuvenation. The results indicated significant improvements in skin laxity, wrinkles, and texture following treatment. Patients reported high satisfaction levels, suggesting that the device was effective in achieving nonablative skin rejuvenation.
• Suh et al. (2012): This study investigated the efficacy of radiofrequency (RF) in treating mottled and wrinkled skin. The results demonstrated improvements in skin laxity, wrinkles, and overall appearance. Histological analysis confirmed increased collagen production and remodeling, supporting the beneficial effects of RF in skin tightening.
• Sadick and Mulholland (2004): This study focused on the use of RF energy for subcutaneous tissue heating and cellulite treatment. The results showed a reduction in the appearance of cellulite and improved skin texture. The study confirmed the effectiveness of RF in promoting collagen remodeling and tightening the skin.
• Weiss et al. (2008): This retrospective analysis assessed the efficacy and safety of monopolar RF for facial tightening. The study included over 600 treatments and reported significant improvements in skin laxity, wrinkles, and overall facial appearance. The treatment was well-tolerated, with minimal adverse effects reported.

Ultrasound Skin Tightening
The third most popular skin tightening modality when considering a cosmetic procedure for most users is Ultrasound, which is also a noninvasive procedure, and available in-clinic (procedures such as Ultherapy) and through at-home devices (such as the EvenSkyn Eclipse, which is due to be releasing late 2023). Unlike lasers which uses focused light, or RF that uses focused RF waves, Ultrasound skin tightening uses focused ultrasound waves. The stimulation target is the same, i.e., the dermis layer to increase / stimulate collagen production, to promote skin tightening. From a scientific standpoint, it operates on the principle of selective thermal coagulation, wherein ultrasound energy is delivered to precise depths within the skin, targeting the underlying layers without causing damage to the surface using ultrasound waves. The focused ultrasound waves generate heat in the targeted areas, leading to the denaturation and contraction of collagen fibers, and triggering a wound healing response. This process stimulates the production of new collagen & elastin fibers, which gradually replaces the old and damaged collagen, resulting in firmer and tighter skin. Ultrasound devices used for skin tightening purposes have specialized transducers (much like how RF devices have RF generators) that emit controlled ultrasound energy at specific depths. Similar to RF treatments, ultrasound treatments are often performed in multiple passes over the treatment area to ensure even coverage and optimal results. Generally, for the vast majority of the population, ultrasound skin tightening treatments tend to be well-tolerated, causing minimal discomfort and no downtime, making them a popular choice for individuals seeking non-surgical skin rejuvenation.

Scientific Studies on Ultrasound Skin Tightening

• Alam et al. (2008): This prospective cohort study evaluated the efficacy of ultrasound skin tightening on the face and neck. The results showed significant improvements in skin laxity and texture, with high patient satisfaction. Objective measurements and clinical assessments confirmed the effectiveness of ultrasound in achieving skin tightening.

• Fabi et al. (2015): This prospective cohort study assessed the efficacy of ultrasound skin tightening on the face and neck. The results demonstrated improvements in skin laxity, wrinkles, and overall appearance. Objective assessments and patient satisfaction scores supported the efficacy of ultrasound treatment in skin tightening.

• Makin and Durrani (2014): This review article discussed the potential of ultrasound for skin tightening. It explored the mechanisms of action, clinical applications, and outcomes of ultrasound treatment. The review highlighted the ability of ultrasound to stimulate collagen production, improve skin elasticity, and achieve significant skin tightening effects.

Comparing Laser, Ultrasound and Radiofrequency Skin Tightening Modalities
Radiofrequency (RF) skin tightening, ultrasound skin tightening, and laser skin tightening are generally considered safe noninvasive procedures. Although using differing technologies, each of these treatments stimulates collagen & elastin production, and helps improve skin laxity. For a candidate interested in noninvasive skin tightening intervention using newer technological therapies, it is important to consider the long-term safety for each of these methods, and to do so with reference to the scientific evidence available on each, along with other factors such as patient comfort, timeframe for results to appear, how frequently each has to be done, how long the results last after each session, etc. In the experience of users and practitioners alike, it has become apparent that RF and ultrasound skin tightening enjoy advantages over laser skin tightening as they are less likely to cause damage to the skin's surface, given how hot most lasers operate, exacerbating concerns around unintended fat loss, especially for in-clinic treatments (vs using at-home devices) given the significantly higher power threshold of commercial machines. Also, Botox and fillers, which have long been the go-to anti-aging treatment for wrinkles, while effective in reducing wrinkles and fine lines, involve the injection of substances into the skin and may carry potential risks such as allergic reactions or localized side effects. Therefore, given specificity of targeting, lower operating temperature, and with no use of injectable substances being made, in terms of long-term safety, RF skin tightening and ultrasound skin tightening are generally considered safer alternatives to laser, as well as Botox and fillers

Radiofrequency or Ultrasound: Which is best for skin tightening?
Both radiofrequency (RF) skin tightening and ultrasound skin tightening have shown effectiveness in maintaining facial volume and stimulating new collagen production. Following are examples of scientific evidence and rationale supporting the benefits of each modality:

• RF Skin Tightening: RF technology has been shown to induce collagen remodeling and stimulate the production of new collagen fibers in the dermis. A study by Alexiades-Armenakas et al. (2003) demonstrated increased collagen synthesis and neocollagenesis following RF treatment. This helps to improve skin elasticity, firmness, and overall volume. RF also has the ability to penetrate deeper into the skin, targeting the underlying layers where collagen resides, making it an effective modality for promoting collagen regeneration.

• Ultrasound Skin Tightening: Ultrasound energy has been found to induce thermal coagulation and mechanical disruption in the deep dermal layers, leading to tissue tightening and collagen remodeling. A study by Alster and Lupton (2007) reported that ultrasound treatment resulted in increased collagen production and neocollagenesis, contributing to improved facial volume and skin tightening. Ultrasound has the advantage of precisely targeting specific depths, allowing for controlled heating and collagen stimulation in the desired areas.

Both modalities having demonstrated the ability to maintain facial volume and stimulate new collagen producing, choosing between RF and ultrasound skin tightening may depend on individual preferences, as well as treatment objectives. RF is known for its ability to target deeper layers of the skin, making it suitable for overall facial volume enhancement. Ultrasound, on the other hand, provides precise targeting and may be particularly beneficial for treating specific areas where collagen production needs to be stimulated. As a general rule, if global results are desired, i.e., all over the face, neck and upper chest/body generally, RF presents as a more suitable choice.

Important Safety Considerations: It's worth noting that individual responses to these treatments may vary, and consulting with a qualified medical professional is essential to determine the most suitable approach based on specific needs and goals. Additionally, long-term maintenance of facial volume and collagen stimulation may require multiple treatment sessions and a consistent skincare regimen to maximize the benefits of either modality.

Cost Considerations
The average price of in-clinic radiofrequency (RF) and ultrasound skin tightening treatments can vary depending on factors such as the geographical location, the provider's expertise, and the specific body area being treated. Generally, a single session of in-clinic RF or ultrasound treatment can range from $300 to $500 or more. Multiple sessions may be need or recommended (by a practitioner, if done in a clinical setting) for optimal results, which can significantly increase the total cost.

At-home devices, such as the widely-acclaimed EvenSkyn Lumo and other similar skin tightening devices, while needing to be used more frequently than in-clinic treatments to see similar cumulative results, offer a more affordable alternative to in-clinic treatments. These devices typically range in price from $100 to $500, depending on the brand, features, power of the devices, as well as the technologies incorporated. While the initial investment may be higher than a single in-clinic session, at-home devices can be used repeatedly over an extended period, making them cost-effective in the long run. With the explosive growth in the ‘at-home beauty’ market, and with rapid advancements in miniaturization, many users are increasingly opting for at-home beauty devices in lieu of going to clinics and spas for skin tightening treatments. However, where severe anti-aging concerns exist, consultation with a dermatologist or plastic surgeon may be the apt choice, where the likely recommendation often would be surgical, or at the very least, more involved in-clinic treatments. 

Further, when comparing results of at-home devices with in-clinic sessions, it is important to note that outcomes can significantly vary. In-clinic treatments are typically performed by trained professionals using more powerful and advanced devices, which may yield more noticeable and immediate results. However, at-home devices can still provide significant improvements in skin tightening and collagen stimulation when used consistently and as directed over time. The results may be more gradual, but they can still be effective in reducing the signs of aging and improving skin elasticity.

In terms of cost savings, assuming an average in-clinic session costs around $400, and an individual undergoes four sessions per year, totaling as estimated $1600 annually, over two years the total cost adds up to be in excess of $3200. In comparison, if an individual purchases an at-home device, such as EvenSkyn’s flagship Lumo At-Home Skin Tightening device, for $600 and uses it for two years, they could potentially save $2600 or more, while still enjoying warranty coverage from the company.

Finally, it is important to consider and note that individual results, expectations, care preferences, and convenience should be taken into account when deciding between in-clinic and at-home treatments. Consulting with a medical professional, attending physician, or ideally a dermatologist, can help determine the most suitable option based on the individual’s specific needs, budget, timeline and treatment goals.

Changing User Preference: RF & Ultrasound Skin Tightening instead of Botox
As users have looked to take advantage of newer therapies and devices that have become available to the general population in recent years, there has been a notable shift in user preferences away from Botox, and towards radiofrequency (RF) and ultrasound skin tightening treatments. Botox, although effective in reducing wrinkles and fine lines, has faced criticism due to concerns about its potential side effects and unnatural results (where often a certain peculiar paralyzed look to certain parts of the face, which is often seen as an almost unnatural look, has become the easy ‘give away’ that one has undergone a Botox treatments). Users have become more interested in non-invasive options that promote overall skin health and provide natural-looking results, especially treatments (such as RF) that leverage the skin’s natural ability to produce more volume through stimulation and activation.  

There exist a number of reasons why RF and ultrasound skin tightening have gained popularity among older individuals, prime among being the reason that these treatments stimulate collagen production and promote skin tightening without the need for injections or invasive procedures, making them more appealing to those looking for non-surgical options. Secondly, RF and ultrasound treatments are generally considered safe with minimal downtime, and since no products or substances are introduced into a subject’s skin tissue, there’s reduced risk of adverse effects compared to Botox. The natural and gradual improvements in skin texture and elasticity achieved through these treatments also contributes to treatment involving RF & ultrasound being preferred by older users who value more subtle and long-lasting results.

Furthermore, RF and ultrasound skin tightening have shown efficacy in addressing multiple signs of aging, such as sagging skin, wrinkles, and loss of firmness, while Botox and other alternatives often only are able to either provide volume, or reduce the appearance of wrinkles, but often do not tackle most aging related concerns all at once. RF & ultrasound treatments offer a holistic approach to skin rejuvenation, promoting overall skin health and helping to restore a more youthful appearance. The ability of RF and ultrasound to target deeper layers of the skin also makes them effective in addressing skin laxity, which is a common concern among older individuals —again, something Botox and other fillers simply cannot do as they often act as suppressants of motor action, or inert fillers in other instances.

References

Alam, M., White, L. E., Martin, N., Witherspoon, J., Yoo, S., West, D. P., & Dover, J. S. (2008). Ultrasound tightening of facial and neck skin: a rater-blinded prospective cohort study. Journal of the American Academy of Dermatology, 59(3), 410-417.

Alexiades-Armenakas, M. R., Dover, J. S., & Arndt, K. A. (2003). The spectrum of laser skin resurfacing: Nonablative, fractional, and ablative laser resurfacing. Journal of the American Academy of Dermatology, 48(3), 311-321.

Alexiades-Armenakas, M. R., Dover, J. S., & Arndt, K. A. (2008). The spectrum of laser skin tightening: An update. Lasers in Surgery and Medicine, 40(2), 121-128.

Alster, T. S., & Lupton, J. R. (2007). Nonablative cutaneous remodeling using radiofrequency devices. Clinics in Dermatology, 25(5), 487-491.

Fabi, S. G., Goldman, M. P., & Dayan, S. H. (2015). Ultrasound tightening of facial and neck skin: a rater-blinded prospective cohort study. Journal of Drugs in Dermatology, 14(10), 1135-1140.

Makin, I. R., & Durrani, Z. (2014). The potential of ultrasound for skin tightening. International Journal of Women's Dermatology, 1(2), 77-81.

Manuskiatti, W., Triwongwaranat, D., & Varothai, S. (2005). Efficacy and Safety of a Single Microablative Radiofrequency Treatment for Nonablative Skin Rejuvenation. Dermatologic Surgery, 31(7), 916-922.

Suh, D. H., Chang, K. Y., & Son, H. C. (2012). Radiofrequency for the treatment of skin laxity: mottled and wrinkled skin. Journal of Cosmetic and Laser Therapy, 14(5), 223-231.

Sadick, N. S., & Mulholland, R. S. (2004). A prospective clinical study to evaluate the efficacy and safety of cellulite treatment using the combination of optical and RF energies for subcutaneous tissue heating. Journal of Cosmetic and Laser Therapy, 6(3), 187-190.

Weiss, R. A., Weiss, M. A., Beasley, K. L., & Munavalli, G. (2008). Monopolar radiofrequency facial tightening: A retrospective analysis of efficacy and safety in over 600 treatments. Journal of Drugs in Dermatology, 7(8), 718-722.

Weiss, R. A., Weiss, M. A., & Munavalli, G. (2011). Rejuvenation of the aging neck: Combined technologies for complete and optimal results. Journal of Drugs in Dermatology, 10(10), 1114-1122.