Arisa Ortiz, MD, FAAD, the director of laser and cosmetic dermatology at UC San Diego Health in La Jolla, CA, shares a number of pearls on what dermatologists should consider when handling complications from radiofrequency lifting and tightening devices.
The Dermatologist: What are some of the most common complications from radiofrequency lifting and tightening devices? How often are they seen, and are these more common among providers who are not medically trained?
Dr Ortiz: I’ll say that certainly the complication risk is always higher in practitioners that are not trained in these procedures. The more knowledge they have about skin anatomy and device knowledge, then obviously, the less risk of complication.
In terms of radiofrequency, the newer technologies are safer than they have been in the past. The protocols have employed lower energies with multiple passes rather than high energy and fewer passes. So, there’s fewer complications these days. With the original monopolar radiofrequency there was some risk of skin atrophy, but we really don’t see that anymore due to a change in the protocol (lower energies, multiple passes).
These days, there are different types of radiofrequencies. For example, fractional radiofrequency, or “needle radiofrequency”, is when you have tiny little needles that go into the skin and deliver radiofrequency energy. That can be very technique‑dependent, because the needles have to be completely inserted into the skin. If they’re not depressed completely, then you could be firing energy too superficially, which leads to side effects like hyperpigmentation, or scarring.
The Dermatologist: What clinical features would providers need to recognize?
Dr Ortiz: With any energy‑based device, anytime you’re putting heat in skin, there’s always risk of scarring. For monopolar radiofrequency and noninvasive radiofrequency, I avoid using any type of anesthesia, because I like that feedback from the patient. So, if they tell me it's too hot, then I definitely make sure to turn down the energy.
With more invasive devices, like subsurface monopolar radiofrequency, which is where a probe goes underneath the skin to deliver subdermal radiofrequency, tumescent anesthesia is required. This procedure is associated with prolonged downtime and a common expected side effect is significant swelling. It’s important to stay away from danger zones, because there is a higher risk of temporary nerve palsy compared to nonvinvasive radiofrequency. This is generally temporary and does resolve with time, but it can last several months.
The Dermatologist: Are there any other techniques that you would recommend to maximize the results of any of these devices?
Dr Ortiz: Patient selection is probably the most important factor when using noninvasive radiofrequency. Younger patients with less laxity are going to do better than if you have a patient who is a little bit older with more laxity.
You also want to consider whether the patient is just looking for tightening or textural improvements, as well. So, if they would like both, textural and tightening, then you may want to consider something like fractional radiofrequency or needle radiofrequency, because that will address not only tightening, but also texture.
And then we need to consider contraindications. So, for radiofrequency, a contraindication would be someone who had a pacemaker or a cochlear implant.. That’s more so for monopolar than bipolar radiofrequency, but if a patient has a pacemaker, then I just avoid any type of radiofrequency, because there are other tightening options, like microfocused ultrasound.
If you have a patient who has a darker skin type and you’re performing needle radiofrequency, then you should use a device that has coated needles. These needles come silicone‑coated in the proximal portions to protect the epidermis and decrease the risk of hyperpigmentation. Non-coated needles ablate all the way through the epidermis into the dermis. So, if you have a darker-skinned patient, then you want to use coated needles or a noninvasive form of radiofrequency to decrease the risk of side effects.
The Dermatologist: Are there any treatment options for addressing these complications?
Dr Ortiz: Sometimes time alone can help things like hyperpigmentation. You can also consider bleaching creams or superficial lasers, like the 1927-nm thulium, if you want to speed up lightening of hyperpigmentation. For atrophic scarring, you can consider correcting with dermal fillers. For scarring, you can consider nonablative resurfacing.
The Dermatologist: Do you have any other recommendations for providers using these devices in their practice?
Dr Ortiz: So, just like with anything, I think it’s important to only use devices that you are trained on and have good experience with. If you have a new device, then make sure to always use the most conservative settings until you become comfortable with it. Lastly, it’s always good to identify a mentor that can help guide you through new treatments.