Radio Frequency Treatment: the New Way to Spend Lunchtime!
Thursday, October 18, 2012
Patient demand for lunchtime cosmetic procedures is sky
rocketing. No redness, no bruising, no trace of work - instead,
truly effective results are the criteria that our patients want.
Other than our tried and true core devices such as pulse radio
frequency treatment (intense pulsed light [IPL]), light-emitting
diodes (LED), BLU-U®, and microdermabrasion, what can we
Fractional resurfacing, my most popular laser procedure, is
disqualified for a stealth, lunch-hour procedure owing to the
pre-operative topical anesthesia time and the post-operative edema
and erythema. Thermage is possible, but I still administer pain
medications to most patients, necessitating at least an hour off
work for it to wear off, and certainly patients cannot expect to
return to any type of work that involves safety! (My interior
designers say it makes them more creative for the rest of the
New radio frequency devices
At the recent American Society of Cosmetic Dermatology and
Aesthetic Surgery (ASCDAS) annual meeting in Las Vegas, NV, we were
introduced to a new cadre of monopolar and bipolar radio frequency
devices. So, what is their niche? From a practice management
perspective, the new pulse radio frequency devices offer a fairly
inexpensive investment (the price range is 30,000 to 80,000 US
dollars. Some require purchase of tips and other disposables so
beware of hidden costs). Physician extenders may be trained to
deliver the treatments. Rather than one intense treatment, these
devices may require a series of 3-5 treatments at a range of weekly
to monthly intervals. Typically, this radio frequency series is
repeated annually. In general, radio frequency devices are designed
to be small and elegant, and require a standard electrical
Do they work?
From a treatment perspective, radio frequency devices work! Many
studies on monopolar devices show promising results (Table 1). My
patients have been impressed with the Pelleve™ system (Ellman
International, Oceanside, NY) as an augmentation, or in lieu of
Thermage procedures (Solta Medical, Hayward, CA). This device has
several wands that range in size for the treatment of facial
rhytids, for which it is Food and Drug Administration approved. I
do three passes per area, examples of which include the upper
eyelid, eyebrow, and forehead; the jaw line and lower face; the
neck; and the cleavage. Each pass requires heating the skin from
40-42°C in the upper face and neck, and 40-44°C in the lower face
and chest. Patients report that it feels like a warm massage.
Studies have shown a 25% improvement in the number and depth of
rhytids after only one treatment with the Pelleve™ system, and this
improvement is sustained at six months.1 One challenging
patient came to me after having undergone treatment with Smart Lipo
of submental fat. She had developed asymmetry where the left side
of her submental area and neck were tight but the right was lax.
After two Pelleve™ treatments, she feels that she needs only one
more treatment session. We could have chosen another modality, but
because Pelleve™ requires no topical lidocaine or pain medications,
it was the patient's first choice. Excilis (BTL Industries) is a
monopolar radio frequency treatment for rhytids that can also be
used for the face and body, and has no disposables.
Table 1. Key studies evaluating the effects of monopolar
Type of Study
Fitzpatrick et al4
Multicenter nonrandomized blinded clinical trial
Objective and subjective improvement in periorbital wrinkles and
Bassichis et al5
Comparative nonrandomized nonblinded
Objective improvement in brow elevation, brow asymmetry observed
in many patients, and the majority of patients did not perceive a
Nahm et al6
Comparative non randomized nonblinded split face
Objective brow elevation observed in all patients by 3
El-Domyati et al7
Subjective notable improvement in skin tightening and wrinkles
in periorbital and forehead regions which was more pronounced 3
months after treatment; objective increase in collagen
Jacobsen et al8
Nonrandomized nonblinded clinical trial
Subjective improvement in lower face skin tightening
Alster and Tanzi9
Nonrandomized nonblinded clinical trial
Subjective improvement in moderate cheek laxity and nasolabial
Weiss et al10
Retrospective chart review
Increased rate of unexpected adverse side effects in single pass
high energy treatment compared to lower energy multiple pass
Ruiz-Esparza et al11
Nonblinded nonrandomized case study
Objective reduction in active acne lesions and subjective
improvement in scarring
Javate et al12
Objective clinical improvement in wrinkles with electron
Other radio frequency devices, such as Alma's Accent Elite,
target fat. The concept is the same: radio frequency energy
essentially bypasses the epidermis and converts into heat in the
deeper tissues, where it creates a controlled wound, fibrosis, and
contraction of collagen. Fibrous septae form a net-like structure
throughout the surrounding fat lobules. Theoretically, when radio
frequency energy heats the septae, they shrink and contract the
lobule. In addition, when a critical temperature is reached, fat
liquefies and drains into the circulation. This method of fat
destruction is the opposite of that of Zeltiq®, which
freezes the fat first. When the frozen fat cell melts, it undergoes
cell lysis - just like the freeze/thaw cycle with liquid nitrogen
that destroys cells. The Accent Elite claims to shrink the dermis
and subcutaneous tissues to improve overall laxity (eg, under the
arms) in six treatments. Velasmooth™ and Aluma™ are also in this
radio frequency/lipolysis category. Studies of the Velasmooth™
system have shown an overall clinical improvement of 50% in 90% of
patients. Erythema is the most common side effect.2
Fractional radio frequency
Fractional radio frequency systems such as MatrixRF™ and
Endymed™ are now available. The fractional resurfacing applicator
offers multi-level rejuvenation; skin resurfacing and fat
lipolysis. This technology uses multisource radio frequency to
deliver microscopic treatment points - both superficial and deep -
and, like all radio frequency devices so far, is safe in all skin
types. The MatrixRF™ device leads to a 90% improvement in skin
brightness, skin tightness, and skin smoothness and wrinkling in
most patients after three treatments.3
Radio frequency plus light devices include Elos™, Polaris™, and
eMax™. The concept is that electro-optical energy can deliver
multiple treatment solutions - eg, for rhytids, pigment and
vascular lesions - in one treatment, thereby utilizing less energy.
Theoretically, this is safer for patients.
Rather than being uni- or bipolar, the future of radio frequency
devices may lie in being tripolar or even utilizing up to eight
different poles and magnetic energies. Using multiple poles may
allow lower energies to achieve successful results at lower pain
In addition to radio frequency, we now have available new
non-light devices, such as ultrasound. Solta's
Liposonix® (Figure 1) promises to reduce abdominal girth
by 2.5cm per session by using sound waves to disrupt and destroy
fat. It is user-friendly, minimally painful, and has no side
effects other than temporary bruising. Ultrashape® is
also in this category.
Figure 1. Images taken before and 8 weeks after
Liposonix® treatment, showing a 5cm reduction in
abdominal girth. Image courtesy of Solta Medical Aesthetic
Laser, intense light, and now non-photon-based technologies are
expanding our field of therapeutic options for non-invasive
cosmetic surgery. I urge physicians and physician extenders to know
the precise mechanism of action of each device. Too often, I ask
operators what wavelength or energy they used and the response is:
"I don't know. I rent the machine and the rep brings it to my
office." These are powerful tools and can deliver powerful side
effects, even in the hands of the best operators. Know thy device
well. In my opinion, our oath to "Do no harm" applies significantly
to our work as cosmetic surgeons when providing elective procedures
to enhance our patients' lives.
- Rusciani A, Curinga G, Menichini G, Alfano C, Rusciani L.
Nonsurgical tightening of skin laxity: a new radiofrequency
approach. J Drugs Dermatol 2007; 6:381-6.
- Alster TS, Tanzie EL. Cellulite treatment using a novel
combination radiofrequency, infrared light and mechanical tissue
manipulation device. J Cosmet Laser Ther
- Hruza G, Taub AF, Collier SL, Mulholland SR. Skin rejuvenation
and wrinkle reduction using a fractional radiofrequency system.
J Drugs Dermatol 2009;8:259-265.
- Fitzpatrick R, Geronemus R, Goldberg D et al. Multicenter study
of noninvasive radiofrequency for periorbital tissue tightening.
Lasers Surg Med 2003;33:232-242.
- Bassichis BA, Dayan S, Thomas JR. Use of a nonablative
radiofrequency device to rejuvenate the upper one third of the
face. Otolaryngol Head Neck Surg 2004; 130:397-406.
- Nahm WK, Su TT, Rotuna AM, Moy Ronald. Objective changes in
brow position, superior palpebral crease, peak angle of the
eyebrow, and jowl surface area after volumetric radiofrequency
treatments to half of the face. Dermatol Surg
- El-Domyati M, El-Ammawi TS, Medhat W. Radiofrequency facial
rejuvenation: evidence-based effect. J Am Acad Dermatol
- Jacobsen LG, Alexiades-Armenakas, M, Bernstein L, Geronemus RG.
Treatment of nasolabial folds and jowls with a noninvasive
radiofrequency device. Arch Dermatol
- Alster TS, Tanzi E. Improvement of neck and cheek laxity with a
nonablative radiofrequency device: a lifting experience.
Dermatol Surg 2004;30:503-507.
- Weiss RA, Weiss MA, Munavalli G, Beasly KL. Monopolar
radiofrequency facial tightening: a retrospective analysis of
efficacy and safety in over 60 treatments. J Drug
- Ruiz-Esparza J, Gomez JB. Nonablative radiofrequency for active
acne vulgaris: the use of deep dermal heat in the treatment of
moderate to severe active acne vulgaris: a report of 22 patients.
Dermatol Surg. 2003;24:333-339.
- Javate RM, Cruz RT, Khan J, Trakos N, et al. Nonablative 4-MHz
dual radiofrequency wand rejuvenation treatment for periorbital
rhytides and midface laxity. Ophthal Plast Reconstr Surg