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Surgery and Cosmetics

Radio Frequency Treatment: the New Way to Spend Lunchtime!

Ellen Marmur, Margarita Lolis

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 offer?

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 day!)

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 outlet.

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 radio frequency

Authors

Type of Study

Results

Fitzpatrick et al4

Multicenter nonrandomized blinded clinical trial

Objective and subjective improvement in periorbital wrinkles and brow elevation

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 cosmetic benefit

Nahm et al6

Comparative non randomized nonblinded split face

Objective brow elevation observed in all patients by 3 months

El-Domyati et al7

Nonrandomized nonblinded

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 synthesis

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 folds

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 technique

Ruiz-Esparza et al11

Nonblinded nonrandomized case study

Objective reduction in active acne lesions and subjective improvement in scarring

Javate et al12

Nonblinded, nonrandomized

Objective clinical improvement in wrinkles with electron microscopic  correlation 

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 levels.

Non-light devices

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.

Marmur Fig 1

Figure 1. Images taken before and 8 weeks after Liposonix® treatment, showing a 5cm reduction in abdominal girth. Image courtesy of Solta Medical Aesthetic Center.

Conclusions

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.

References

  1. 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.
  2. Alster TS, Tanzie EL. Cellulite treatment using a novel combination radiofrequency, infrared light and mechanical tissue manipulation device. J Cosmet Laser Ther 2005;7:81-85.
  3. 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.
  4. Fitzpatrick R, Geronemus R, Goldberg D et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med 2003;33:232-242.
  5. 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.
  6. 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 2004;30:922-928.
  7. El-Domyati M, El-Ammawi TS, Medhat W. Radiofrequency facial rejuvenation: evidence-based effect. J Am Acad Dermatol 2011;64:524-535.
  8. Jacobsen LG, Alexiades-Armenakas, M, Bernstein L, Geronemus RG. Treatment of nasolabial folds and jowls with a noninvasive radiofrequency device. Arch Dermatol  2003;139:1371-2.
  9. Alster TS, Tanzi E. Improvement of neck and cheek laxity with a nonablative radiofrequency device: a lifting experience. Dermatol Surg 2004;30:503-507.
  10. 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 Derm  2006;5:707-712.
  11. 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.
  12. 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 2011;27:180-5.
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