What is the best in-office treatment for tightening loose skin?

This column first appeared in Valerie Monroe’s newsletter, How not to argue your facewhich you can subscribe to in Substack.

Q: You mentioned recently Thermage and Softwave in relation to the tightening of loose skin. I am asking about Thermage, because it is available near me. But are other RF lasers just as effective for tightening? I’ve noticed wildly different prices in my area for different lasers and I’m wondering if the cheaper options aren’t as good. Are all created equal? Second, is there an antiaging preventive effect to using lasers earlier in life? I’ve heard some say that, for example, early use of Botox has preventative effects on wrinkles/lines, but I doubt that’s true.

And …

Q: My question is about the jowls. Can anything be done to tighten them and minimize sagging of the chin, jaw and neck? I used to have Bucket under my chin, and even though I felt like I was being attacked by killer wasps, the results were okay. My understanding is that Kybella melts fat, and the craziness must be caused by something more insidious, like gravity or genetics. What are people doing these days to keep the under chin area in shape?

ONE: I will pass this on HNTFUYF DermDiva Heidi Waldorf, MD, in a minute, but first: When I read phrases like “antiaging preventative effect” and “tremors must be caused by something more insidious, like gravity or genetics,” though I understand the feelings behind them (I have them too), it makes me sad. Our soul and body are so vulnerable! And our largely ageist beauty culture constantly reminds us how badly we’re doing.

Here we are, walking precariously along the high wire between the darkness that delivered us and the darkness that awaits us — in what right now feels like a strong wind — and what encouragement do we get? We think about our loose legs and crow’s feet. I want to remind you that aging, gravity and genetics are not insidious, but each a miracle. You you are a miracle, with all your imperfections. Maybe it’s time to reintroduce yourself.

Now, if you decide to take advantage of in-office beauty treatments for whatever reason—and if the reason is good enough for you, it’s good enough for me—here are some general guidelines for getting the best results.
“As the saying goes, ‘Many roads lead to Rome’ — or to put it less elegantly, ‘There are many ways to skin a cat,’” says Waldorf. “What I mean is that there are many options to achieve the same goal.”

That’s why Waldorf’s recommendation is to choose the doctor, not the device.

Why; Because tightening can be achieved in many ways, depending on the condition of your skin. It can be done without breaking the skin using radio frequencies or ultrasound. Or it can be done by resurfacing the skin using various lasers, radio frequencies, radio frequency microneedling, or some combination of these.
To clarify for the first time reader who seems to be confused about what these devices are: Laser stands for light amplification by stimulated emission of radiation. Waldorf explains:

About that “electrical resistance of the dermis” — once I figure out what exactly that means, I’ll let you know. Meanwhile, “There are no clear side-by-side comparisons of these devices, so I can’t say if one is ‘better’ than the other,” says Waldorf. “However, we know the amount and type of heat each device can produce and the depth it can penetrate. This is what should guide the recommendation of a device, based on the quality of your skin and subcutaneous tissue.”

The main thing to keep in mind is that loose and photodamaged skin with insufficient support is less likely to show improvement using a non-invasive tightening device without also resurfacing the skin. Younger, less damaged skin with good support will get the most benefits from non-invasive tightening alone, says Waldorf. If your skin falls somewhere between these two categories, an honest discussion with your doctor will help you understand whether the results will be worth it, given your expectations and budget. I say this a lot, because it’s true: The less a device has to do, the better it works.

But it’s not your job to figure out which device will give you the most bang for your buck or where to find the cheapest treatment. The is it’s your job to ask a doctor (not an esthetician) serious questions about what a recommended device can do for you, and accept the answer (even when it’s not what you want to hear). For example:

Preventative skin care (sunscreen, no smoking, healthy diet) and starting targeted treatments at the first signs of aging can help keep your skin looking fresh longer, says Waldorf. I’ll put it another way: If you’re worried about wrinkling and sagging as you age (a natural phenomenon), you can start in-office treatments when you first notice any wrinkles or sagging that bother you, which can give you more visible results for longer period of time.

Starting an annual or biannual non-invasive tightening procedure when the skin starts to lose its springiness can slow the march of time on your face, says Waldorf. Eventually, though, as long as you live and breathe, your face will age. you would be wise to accept it. Because there is a rabbit hole here I don’t want you to fall down.

As for neurotoxin injections as a wrinkle preventative, Waldorf says it’s true that “toxin injected between a squint’s eyebrows before wrinkles start to form can inhibit their development. You can also be careful about wearing sunglasses, which will help prevent squinting as well as protect your eyes from UVA/UVB damage.