What I Tell Patients Before They Spend Thousands on Nonsurgical Skin Tightening

Jing Castro is a board-certified nurse practitioner and the founder of Blue Sky Laser & Tox.

One of the most common things I hear during consultations is, “I want to tighten this,” usually while someone is pulling back the skin along their jawline or neck.

Sometimes they come in already asking for a specific treatment because they saw it on social media or a friend had it done. XERF, Ultherapy PRIME, and other energy-based treatments have made nonsurgical skin tightening much more visible to consumers. But before I talk about a device, I want to understand what the patient is actually seeing. That is because not everything we call “loose skin” is really just loose skin.

Aging is complicated. We lose collagen and elasticity, but we also experience changes in facial fat, bone structure, muscle, pigmentation, and skin texture. Sun damage can make the skin look older even when laxity is minimal. Loss of facial volume can create heaviness or shadowing that a tightening device alone will not correct.

I’m a board-certified nurse practitioner specializing in aesthetic medicine and the founder of Blue Sky Laser & Tox in Arlington, Virginia. In my practice, I work with injectables, lasers, and energy-based treatments, and one of the biggest lessons I’ve learned is that choosing the right patient matters just as much as choosing the right technology.

The first question shouldn’t be, “Which machine is best?”

Patients understandably want to know which device gives the best result. I don’t think there is one answer. Instead, I look at the person’s anatomy, skin quality, degree of laxity, facial volume, age, goals, tolerance for discomfort and downtime, and how subtle or dramatic a change they are expecting.

If someone has mild to moderate laxity and wants gradual improvement without surgery, an energy-based tightening treatment may make sense. If someone has significant excess skin and is expecting the result of a facelift, I would rather have an honest conversation than sell them a treatment that is unlikely to meet their expectations.

This is probably the most important thing I tell patients: nonsurgical skin tightening is still nonsurgical. It can improve firmness and create subtle lifting in the right patient, but it does not remove excess skin. Even the manufacturer of Ultherapy PRIME makes clear that the treatment does not duplicate the results of a surgical facelift.

I think being transparent about that actually makes patients happier. Aesthetic treatments are elective. Doing nothing is always an option, and I would rather a patient wait than spend money because they feel pressured to “fix” something.

Different technologies work differently

Another misconception I often see is the idea that all tightening devices are basically doing the same thing. They aren’t. XERF, for example, is a newer noninvasive monopolar radiofrequency treatment. It uses two radiofrequency frequencies, 6.78 MHz and 2 MHz to deliver thermal energy at different tissue depths. The goal is to create controlled heating that can lead to collagen contraction and remodeling over time.

There is emerging research behind this dual-frequency approach. A 2024 histologic study reported changes related to collagen remodeling, although that research included authors affiliated with the device manufacturer, which is something I think consumers and clinicians should keep in mind when interpreting early data. More recent clinical research has also evaluated facial laxity after XERF treatment, but it remains a relatively new technology compared with some established devices.

Ultherapy PRIME works differently. It uses microfocused ultrasound with real-time imaging. The provider can visualize tissue during the treatment and deliver ultrasound energy at defined depths below the skin. That visualization is one feature I find particularly interesting from a clinical standpoint. We are not all built exactly the same underneath the skin, so knowing where energy is being delivered matters.

Microfocused ultrasound also has a larger body of published research behind it. A 2025 systematic review and meta-analysis of microfocused ultrasound with visualization included 42 studies and found that most patients demonstrated some degree of aesthetic improvement, although the authors also noted limitations in the evidence and called for better-designed studies.

That last part matters. In aesthetics, “clinically studied” should not automatically be translated into “guaranteed result.”

More energy is not always better

There is a tendency in aesthetics to assume that stronger treatment equals better treatment. I don’t believe that. With energy-based devices, the goal is controlled treatment of the correct tissue—not simply delivering as much energy as someone can tolerate.

This is where provider experience and understanding of anatomy become especially important. Facial structure, tissue thickness, volume and treatment area all need to be considered. A treatment that makes sense for a fuller lower face may not be the same treatment I would choose for someone with a thin face who is already concerned about looking hollow.

This is also why I’m cautious about patients choosing treatment settings based on what they saw someone else receive online. Your face is not their face. Treatment should be customized rather than copied.

The result usually isn't instant, and that's a good thing

Patients often ask me when they will see the final result. With collagen-stimulating treatments, I tell them to think in months rather than days.

Some people may notice an early tightening effect, but much of what we are trying to accomplish happens gradually as tissue responds and collagen remodels. Research on microfocused ultrasound, for example, commonly evaluates improvement around the three- and six-month marks rather than just immediately after treatment.

I actually like explaining this because it changes the patient's expectations. The goal is not necessarily to walk out looking dramatically different. Many of my patients don't want people asking, “What did you have done?” They want to hear, “You look good.” That is a very different goal.

Skin tightening also doesn’t replace skin care

A tighter jawline and healthy-looking skin are not the same thing. Someone can have very little laxity but significant sun damage, redness, rough texture, or pigmentation. Another patient may have beautiful skin quality but be bothered by early jowling. Those problems may need completely different treatments.

This is why I prefer comprehensive plans instead of treating one concern in isolation. Depending on the person, that might mean combining skin tightening with treatments aimed at pigmentation or texture, injectables when appropriate, and a simple home routine built around sunscreen and barrier health.

That does not mean doing everything at once. In fact, I often think the better approach is to prioritize. I’ll tell patients: there are several ways we can approach this, they cost differently and use different technologies, so let’s decide what matters most to you first.

There are risks, even when there is “no downtime”

“Noninvasive” sometimes gets interpreted as “risk-free,” and those are not the same thing. Temporary redness, swelling, tenderness or discomfort can happen after energy-based treatments. Published research on microfocused ultrasound has generally found a favorable safety profile, but reported adverse events have included redness, swelling, bruising, tenderness and temporary sensory changes. Rare complications have also been described.

This is one reason I would never choose an aesthetic procedure based only on a device name or an online before-and-after photo. Ask who is performing your treatment. Ask how often they use the technology. Ask what they think is causing the concern you are seeing. Ask what happens if you do nothing. And ask what result they realistically expect for your face.

A good consultation should sometimes end with a provider telling you that you don't need the treatment you came in asking for.

My biggest advice: treat the person, not the trend

Technology in aesthetics is moving quickly, and I find that exciting. Newer platforms such as XERF give providers additional ways to approach tissue tightening, while technologies such as Ultherapy PRIME continue to evolve established methods of microfocused ultrasound treatment.

But I don't think patients need to chase every new device. If someone comes into my practice asking, “Which skin-tightening treatment should I get?” my answer starts with another question: “What are you actually hoping to change?”

Once we answer that, the technology becomes much easier to choose. The best aesthetic treatment is not necessarily the newest, strongest, or most expensive one. It is the treatment that matches your anatomy, your skin, your expectations, and your comfort level with the process.

And sometimes, after we go through all of that, the right answer is to wait. In aesthetic medicine, knowing when not to treat can be just as important as knowing how to treat.

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