Patient selection for these noninvasive tissue tightening of the face and periorbital areas remains the most important indicator of patient outcome. While no hard-and-fast rules are present, generally speaking, patients must be screened for their emotional and physical appropriateness for these procedures. This section will attempt to define the best practices for patient selection.

The best patients for noninvasive procedures such as RF and ultrasound rejuvenation are those who are not ready for surgery medically, emotionally, or financially. In other words, they may have insufficient skin laxity to warrant surgery, have fears of more invasive procedures, or be unable to afford the cost of a large surgery (which often includes operating room and anesthesiology costs in addition to the price of the procedure). Most good candidates are in their thirties to forties and have mild to moderate skin laxity. Older patients who have already had a surgical lifting procedure, have excellent skin quality, or who cannot or will not undergo surgery may also be treated. (Anecdotally the oldest patient one author has treated with radiofrequency tissue tightening was in her early eighties.) Clinically, good candidates for treatment present with periorbital, forehead, jawline, or cheek laxity, marionette lines, pronounced nasolabial folds, and early submental bulging [14].

A major advantage of these therapies is that patients of all skin types can be treated safely even during periods when sun exposure is expected. Although lasers can cause discoloration in patients of Fitzpatrick skin type IV–VI, neither RF nor ultrasound treatments deliver light energy or significant heat to the epidermis and therefore are unlikely to disrupt melanin. Multiple studies have demonstrated the safety of these two treatment modalities for patients with skin of color [5, 15, 22, 23]. The importance of having “color-blind” options can’t be understated. Individuals with skin of color are at greater risk of prolonged or even permanent hyper- or hypo-pigmentation after procedures that impact melanocytes. Heat absorption by pigmentation can also lead to secondary blister and scar formation. Because the risk of keloid formation is generally higher in skin of color, surgery is not always a good option.

While treatment is generally safe, there are patients who should not undergo monopolar RF procedures like Thermage. Contraindications for monopolar RF include a pacemaker or any implanted defibrillating device, because the patient must be grounded and becomes part of the circuit. Contraindications for all RF include predisposition to hypertrophic scarring; koebnerization; oral isotretinoin within one year prior; pregnancy; and metallic implants, previously radiation, medical, or cosmetic tattoo (including permanent makeup) in the treatment area. Heating dermal “implants” like tattoo ink can lead to a burn and even scarring. Patients with a history of herpes virus in the area of treatment should be given oral prophylaxis to prevent outbreak [14, 24–26]. It should be noted that RF has been shown to be safe over dermal fillers like hyaluronic acid, calcium hydroxyapatite, or poly-l-lactic acid [27–29]. In the opinion of the authors, care should be taken to avoid edematous, ecchymotic, or non-intact skin because fluence output is based on the device’s measurement of skin impedance, so soft tissue augmentation is best performed immediately after, not before, Thermage. However, Dr. Waldorf has treated patients with mild to moderate acne, including cysts, without adverse events (and anecdotally often with improvement). Cysts are treated with intralesional dilute corticosteroids at the time of treatment.

For the Thermage Eyes procedure, metallic ocular eyeshields like those used for laser procedures must be avoided because heated metal can cause ocular injury. Instead plastic ocular eyeshields must be used whenever treatment immediately over the eye itself (rather than over the brow) is planned. No eyeshield should be inserted (and eyes should accordingly not be treated) if a patient has had a recent corneal shield, ocular surgery, or a corneal abrasion, without surgical clearance from that treating physician. Indeed it is generally recommended that patients wait to two or three months to have the eyelids treated with RF after having LASIK surgery [30] unless cleared by their surgeon in advance.

Contraindications for ultrasound include a predisposition to hypertrophic scarring or problems with wound healing. While prior cosmetic or surgical treatments (laser, RF, surgical lifting, or filler injections) are nearly inevitable in the population seeking this form of treatment, as with RF, it is best to wait until any edema or purpura is gone before performing the procedure. Similarly, active skin wounds, severe or cystic acne on the face and/or neck, and infections should be treated in advance. Pregnancy is a contraindication [15, 31, 32]. While any of the above stated issues can be concerning for treatment, many patients are acceptable even with the aforementioned relative contraindications if there is appropriate discussion and consent prior to the procedure. Additionally, the use of fillers such as Restylane, Perlane, or Juvederm prior to the procedure generally isn’t a problem if the Ultherapy is being done in other areas. One theoretical risk to the patient is that the fillers may degrade quicker, yet there is no particular harm otherwise.

From a psychological standpoint, a few guidelines have been suggested for patients desiring to undergo tissue tightening. Patients should have realistic expectations about the outcomes, risks, pain levels, and benefits of the procedure. While patients may see some improvement immediately, it should be noted that the most significant results are noticeable 3–6 months after RF or ultrasound treatment. Finally, patients should be completely informed of other options for treatment prior to having surgery [33, 34].

It should be emphasized that the most important contraindication for both of these procedures is that of unrealistic patient expectations. Many patients wish to have a procedure performed that is easy, quick, relatively painless, and has the same or better results than surgery, fillers, or neurotoxins. As part of informed consent, patients must be told clearly that results will not be the same as those achieved by surgery. However, improvements can result with the advantage of gradual natural rejuvenation without downtime, a significant advantage for a large percentage of patients. One of the authors, Dr. Waldorf, specifically avoids calling it a “nonsurgical facelift or eyelift” as a way to stress that results will not be the same degree as those resulting from a facelift or blepharoplasty. She also discusses the treatment as part of a 3-dimensional rejuvenation plan that will also include some combination of neuromodulators, soft tissue augmentation, laser resurfacing, and a good cosmeceutical regimen to maximize results. It is important to show prospective patients not only your best before and after photographs but also more typical examples. If the physician or staff suspects that an individual’s expectations cannot be met, it is the physician’s responsibility to dissuade the patient and even to refuse to perform the procedure. In the extreme, body dysmorphic syndrome sufferers will rarely, if ever, be pleased by results. Making sure there is sufficient time for both staff and the physician to interact with a new prospective patient is critical for screening. Dissuading someone from a treatment without causing insult can be difficult and can be addressed gently by saying that the procedure is unlikely to fulfill the patients needs.

Pain tolerance and control can also help determine ultimate patient satisfaction. One of the authors, Dr. Schlessinger, gives all Ulthera patients a combination of ibuprofen, Vicodin, and Ativan one-half hour pretreatment. In his experience, Dr. Schlessinger has found injectable anesthetics to be of little or no use because anesthesia is uneven, leading to greater discomfort when painful areas are encountered. He has similar feelings regarding topical anesthetics, since their depth of anesthetization (the superficial aspect of the epidermis and dermis) is not as deep as the ultrasound’s depth of penetration (deeper aspect of the dermis and subcutaneous area). On the other hand, the combination of vibration, chilling, and oral pain medications has provided a superior effect with less overall discomfort resulting from injectable or topical anesthetics. Those patients who refuse this combination are dissuaded from undergoing the procedure. In Dr. Waldorf’s practice, since the addition of the CPT (comfort pulse technology), Thermage patients no longer require analgesic or amnestic medications, which has resulted in increased patient satisfaction. It was always recommended that topical and injectable anesthetics be avoided with Thermage because of the risk of the hydration and edema altering impedance measurements.

One of many ways to characterize aging is by the loss of collagen, which comprises more than 90 % of the skin’s protein. Photodamage is characterized by the accumulation of abnormal elastin (solar elastosis). Occurring at the boundary between the dermis and epidermis, these two processes result in several clinical changes, including skin laxity and the development of fine lines and deeper rhytides [14, 35, 36].

Ablative resurfacing, which includes dermabrasion, Er:YAG and CO₂ lasers, and chemical peels, works by causing a controlled zone of damage to the epidermis and dermis and then allowing it to regrow/heal with minimal scarring. Reduction of rhytides and an overall tightening is seen immediately after healing, but additional improvement is noted up to 6 months later. The explanation has been that in addition to the manual resurfacing renewing the epidermis, heat extending to the deeper dermis stimulates new collagen formation. Limitations to ablative resurfacing include a prolonged downtime requiring extensive wound care, the risk of bleeding, infections, unexpected scarring, pigmentary changes, and the need for extended vigilant sun protection [35]. Additionally, Fitzpatrick skin types IV–VI generally cannot be properly treated with laser-assisted ablative resurfacing because of the potential of resulting discoloration and scarring from the light source [5]. These problems led to a goal by physicians and scientists to develop procedures to heat the dermis without affecting the epidermis, including the ones outlined in this chapter.