Dr Malone uses fractional radiofrequency for a range of clinical applications at Baylor College of Medicine in Houston, TX.
Radiofrequency technology has expanded significantly over the past decade and is an essential part of a comprehensive aesthetics practice. Devices that harness this technology can be used for an impressive range of clinical applications, including skin tightening, acne scar treatment, cellulite improvement, subcutaneous fat reduction, hyperhidrosis, enlarged pores, rosacea, and improvement of crepey skin. Radiofrequency energy generates heat, inducing controlled thermal tissue damage, and subsequent tissue remodeling accounts for the clinical improvement seen with these devices.1
Laser Focus / Targeted Treatment
Fractional radiofrequency (FR) devices deliver thermal energy to the dermis or subcutaneous tissue via electrodes or microneedles (the reason this procedure is also known as microneedling). Thermal injury can be precisely controlled with temperature and impedance monitoring. Insulated needles and simultaneous epidermal cooling allow for precisely targeted treatment. Like fractional laser technology, which utilizes light as an energy source, FR uses electricity to create noncontiguous zones of thermal injury. Partially denatured collagen stimulates new collagen, elastin, and hyaluronic acid formation. Zones of untreated tissue allow for rapid healing and tissue remodeling without scar formation. The remodeling process yields optimal tightening when a temperature of 67°C is maintained for 3 to 4 seconds. In contrast, ablative laser technology stimulates neocollagenesis but not elastin formation due to excessive heat generation.2-4
Figure. A 60-year old woman, pretreatment, lateral (A) and anterior (B) views; the same woman after one FR treatment to the cheeks, jawline, submentum, and superior neck, lateral (C) and anterior (D) views.
FR satisfies current popular demand for nonsurgical tightening procedures that can be used on all skin types with minimal downtime and risk. Traditional ablative laser technology is restricted by prolonged social downtime, skin phototype restrictions, limited tightening ability, and significant risks including infection, scarring, and dyschromia. Patients are hesitant to have face-lifts due to concerns about scarring, cost, excessive downtime and fear of unnatural appearing results. Surgical quality tightening can be achieved with FR treatment. One blinded randomized study showed an impressive average of 37% laxity improvement after a single FR treatment compared with a traditional surgical face-lift. Lower face and neck tightening can be achieved with just one FR treatment (see Figure).5-7
Face and Neck Applications
Components of neck aging include submental fullness, skin laxity, crepey skin texture, and plastymal banding. Many physicians are hesitant to use ablative laser on the neck due to slower healing and increased risks of infection and scarring. FR is an excellent alternative option that can be used to improve skin texture, brightness, and laxity. In addition, submental fat can be treated directly with FR, or FR can be used in combination with other submental fat reduction techniques such as liposuction or deoxycholic acid injection. An assessment of plastysmal banding is an essential component of the consultation and counseling process because tightening and fat reduction procedures can worsen the appearance of banding.
Brow position is an important component of facial aging that was traditionally corrected with a surgical brow lift. With current demand for nonsurgical rejuvenation, onabotulinum toxin A is a commonly employed alternative that can safely achieve short-term conservative results. FR and other radiofrequency devices have been used as noninvasive alternatives to surgery. Forehead procedures are prone to complications related to sensory nerve dysfunction. Numbness after surgical brow lift is the most common complication, ranging from 2% to 5% and varies based on the surgical approach. Given this, it is not surprising that temporary numbness has been anecdotally reported with radiofrequency-based forehead rejuvenation.8
Axillary hyperhidrosis, although generally considered a medical condition, is often managed as a cosmetic issue. Although onabotulinum toxin A is an extremely effective treatment option for axillary hyperhidrosis, high deductible plans and obstructionist tactics by insurance carriers dissuade many physicians from offering this treatment. Some cosmetic practices offer permanent treatment for axillary hyperhidrosis with a microwave-based energy device that uses thermal energy to target eccrine sweat glands. FR can be used to safely treat axillary sweating through a similar mechanism. Side effects for treatment of axillary hyperhidrosis from microwave-based and radiofrequency treatments are similar and include edema, redness, pain, numbness, and dysesthesia. Although the mechanisms are similar, FR devices have a distinct advantage for a cosmetic practice given their precision and additional uses.9,10
Acne scar management is another common aesthetic concern that can be addressed with FR. Atrophic acne scars are a multifactorial problem that includes volume loss, tissue atrophy and subdermal scarring. Deep boxcar scars and icepicks scars are relatively resistant to treatment and often require excision. Rolling scars respond well to a combination of subcision, collagen stimulation devices and volume replacement with filler. FR, like nonablative and ablative laser treatment, can be used alone or in combination with other modalities such as subcision. Fitzpatrick skin types IV to VI have more limited treatment options due to the risk of temporary and permanent dyschromia. FR has similar efficacy to nonablative fractional laser with less risk of post-inflammatory hyperpigmentation for atrophic acne scarring. As such, FR is currently considered a first-line treatment for shallow boxcar and rolling acne scars in ethnic skin.11-13
Cellulite is a well-known condition that affects more than 80% of adult women and is a frequently cited area of cosmetic dissatisfaction. Focal fat herniation, dermal thinning, and parallel vertical septae arrangement all account for the clinical appearance of cellulite. This multifactorial etiology explains the relative ineffectiveness of topical treatments and tendency for recurrence after treatment with liposuction. FR devices offer a promising noninvasive option for cellulite treatment with a >90% response rate at 6 months follow-up and excellent patient satisfaction.14
Pros for Patients
Radiofrequency treatment is a safe, office-based procedure with minimal risk and downtime. Histologic studies of tissue after radiofrequency treatment do not show evidence of hyaluronic acid filler disruption, which many cosmetic patients may also have had. Patients only have a few days to a week of social downtime and can use makeup the day after their procedure. Social downtime can be further reduced with pulsed dye laser or intense pulsed light bruise treatment 2 to 3 days after radiofrequency treatment. Side effects are transient and include erythema, edema, bruising, pinpoint depressions, paresthesias, nodules, post-inflammatory hyperpigmentation, and blisters. Post-inflammatory hyperpigmentation is rare with dermal treatment and is more commonly seen with subcutaneous treatment for cellulite. Patients tolerate treatment well with a combination of topical and injected anesthesia. Maintenance treatments with FR devices are required approximately every 2 to 5 years.6, 15
Contemporary aesthetic treatment requires a multifaceted approach to address the various aspects of facial aging. Skeletal resorption, fat pad atrophy/hypertrophy, skin laxity, vascular changes, and dyspigmentation all contribute to facial aging. Patients desire convenient, comfortable, and effective treatment with minimal downtime and fast results. FR is frequently combined with modalities that improve superficial skin texture and rhytides like ablative laser resurfacing. This combination is especially effective for perioral rejuvenation. The resurfacing component of this approach provides results within a few weeks, while collagen remodeling and elastin formation take several months. FR treatment is quickly becoming a key facet of cosmetic practices for its ability to improve deep rhytides, generate significant tightening, and improve skin texture.
Dr Malone is a fellowship-trained Mohs surgeon and cosmetics/laser director for the dermatology department at Baylor College of Medicine in Houston, TX.
Disclosure: The author reports no relevant financial relationships.
1. Lolis MS, Goldberg DJ. Radiofrequency in cosmetic dermatology: a review. Dermatol Surg. 2012;38(11):1765-1776. doi:10.1111/j.1524-4725.2012.02547.x
2. Willey A, Kilmer S, Newman J, et al. Elastometry and clinical results after bipolar radiofrequency treatment of skin. Dermatol Surg. 2010;36(6):877-884. doi:10.1111/j.1524-4725.2010.01563.x
3. Hantash BM, Ubeid AA, Chang H, Kafi R, Renton B. Bipolar fractional radiofrequency treatment induces neoelastogenesis and neocollagenesis.Lasers Surg Med. 2009;41(1):1-9. doi:10.1002/lsm.20731
4. Hantash BM, Renton B, Berkowitz RL, Stridde BC, Newman J. Pilot clinical study of a novel minimally invasive radiofrequency device. Lasers Surg Med. 2009;41(2):87-95.doi:10.1002/lsm.20687
5. Alexiades-Armenakas M, Rosenberg D, Renton B, Dover J, Arndt K.Blinded, randomized, quantitative grading comparison of minimally invasive, fractional radiofrequency and surgical face-lift to treat skin laxity. Arch Dermatol. 2010;146(4):396-405. doi:10.1001/archdermatol.2010.24
6. Alexiades-Armenakas M, Newman J, Willey A, et al. Prospective multicenter clinical trial of a minimally invasive temperature-controlled bipolarfractional radiofrequency system for rhytid and laxity treatment. Dermatol Surg. 2013;39(2):263-273. doi:10.1111/dsu.12065
7. Alexiades M, Berube D. Randomized, blinded, 3-arm clinical trial assessing optimal temperature and duration for treatment with minimally invasive fractional radiofrequency. Dermatol Surg. 2015;41(5):623-632.doi:10.1097/DSS.0000000000000347
8. Cho MJ, Carboy, JA, Rohrich RJ. Complications in brow lifts: A systemic review of surgical and nonsurgical brow rejuvenations. Plast Reconstr Surg Glob Open. 2018;6(10):e1943. doi:10.1097/GOX.0000000000001943
9. Abtahi-Naeini B, Naeini FF, Saffaei A, et al. Treatment of primary axillary hyperhidrosis by fractional microneedle radiofrequency: Is it still effective after long-term follow-up? Indian J Dermatol. 2016;61(2):234. doi:10.4103/0019-5154.177789
10. Sundaram H, Kiripolsky M. Nonsurgical rejuvenation of the upper eyelid and brow. Clin Plast Surg. 2013;40(1):55-76. doi:10.1016/j.cps.2012.08.009
11. Zaleski-Larsen LA, Fabi SG, McGraw T, Taylor M. Acne scar treatment: A multimodality approach tailored to scar type. Dermatol Surg. 2016;42(suppl 2):S139-149.doi:10.1097/DSS.0000000000000746
12. Rongsaard N, Rummaneethorn P. Comparison of a fractional bipolar radiofrequency device and a fractional erbium-doped glass 1,550-nm device for the treatment of atrophic acne scars: a randomized split-face clinical study. Dermatol Surg. 2014;40(1):14-21. doi:10.1111/dsu.12372
13. Chae WS, Seong JY, Jung HN, et al. Comparative study on efficacy and safety of 1550 nm Er:Glass fractional laser and fractional radiofrequency microneedle device for facial atrophic acne scar. J Cosmet Dermatol. 2015;14(2):100-106. doi:10.1111/jocd.12139
14. Alexiades M, Munavalli G, Goldberg D, Berube D. Prospective multicenter clinical trial of a temperature-controlled subcutaneous microneedle fractional bipolar radiofrequency system for the treatment of cellulite. Dermatol Surg. 2018;44(10):1262-1271.doi:10.1097/DSS.0000000000001593
15. Shao EX, Lim D. Stability of hyaluronic acid fillers after insulated microneedle radiofrequency treatment [published online September 10, 2018]. Dermatol Surg. doi:10.1097/DSS.0000000000001676