Summary

Minimally invasive procedures to tighten and lift skin give natural results with minimal risk and recovery time. Monopolar radiofrequency deliver a high-frequency electric current—tissue resistance to electrical current, resulting in volumetric heating to the deep dermis and underlying tissue. The resulting heat leads to immediate collagen contraction and a delayed wound healing response, with new collagen formation up to 4 to 6-month post-treatment. The FDA initially approved monopolar radiofrequency (RF) devices to treat periorbital wrinkles. Since then, they have been used to treat laxity of the forehead, cheeks, nasolabial folds, marionette, lines, jawline, and neck. Although the results of RF are not as dramatic as a facelift, over 90% of patients obtain noticeable tightening of the treated areas, and it never looks “pulled.” Another benefit of radiofrequency is reducing fat and tightening the skin by directing energy to target collagen. For example, a patient with flabby upper arms may have more loose skin than fat in this area. In this instance, Prof Moawad might use radiofrequency to tighten the skin first and then remove excess fat. However, if he determines that there is fat mainly in an area, he will remove the fat first and then tighten the skin afterward. “Radiofrequency is a very versatile procedure that can be used on any area of the body – from large areas like the abdomen to minimal areas such as the chin – with the same degree of success.

Heat treatment using optical energy for various types of dermatologic problems has become very popular over the past 20 years. Light-based therapies with lasers and intense pulse light (IPL) technologies have been increasingly used in aesthetic medicine for epilation, removal of vascular and pigmented lesions, reduction of fine wrinkles, and acne treatment. Although useful for a broad range of dermatological indications, limitations also have been realized with light-based therapies. One of the main limitations is that optical energy must penetrate the epidermis to reach the depth of the targeted site. Melanin chromophores absorb optical energy in the epidermis and hair shafts and hemoglobin in the blood. In photo epilation, light-colored hair is challenging to remove because it has low melanin levels and, therefore, may not absorb enough energy to achieve heat destruction of the hair follicle.

Conversely, high pigmentation of the epidermis also poses a problem because it may absorb too much power, potentially causing adverse effects such as burns and hyperpigmentation. Wrinkles respond poorly to treatment with optical energy because collagen fibers do not contain chromophores. These limitations have stimulated investigators to look for new forms of energy that satisfy the principle of selective thermolysis but are devoid of the main disadvantage of optical energy for dermatological applications; that is, a strong interdependence between treatment efficacy/safety and chromophore levels in the epidermis.
The use of radiofrequency (RF) for selective electro-thermolysis has been found to produce a highly efficient heat effect on biological tissue. Unlike optical energy, RF energy depends on the tissue’s electrical properties and not on the concentration of chromophores in the skin for selective heat destruction of targeted sites.

Types of Radiofrequency (RF) Technologies?

Radiofrequency devices can be classified into several configurations based on how the electrical current passes through the tissue. The first type introduced was monopolar RF, which applies energy to tissue via a single electrode tip and a grounding plate. Bipolar RF applies heat to the tissue via 2 points on the tip of a single probe, and penetration depth is estimated at half the distance between the electrodes. Tripolar RF devices were recently introduced; this technology simultaneously uses multiple electrode configurations to heat superficial and deep skin layers. Fractional RF also is a novel technology in which bipolar RF energy is delivered via a minimally invasive approach using a microneedle electrode assembly. This technology generates discrete heat zones of treated tissue to the depth of the deep dermis with fractional sparing of the epidermis and adnexa, thereby inducing a rapid and vigorous wound-healing response along with sustained dermal remodeling and profound new collagen formation.

Monopolar Radiofrequency

Monopolar systems deliver current using one electrode that contacts the skin and another that acts as a grounding pad. The electrode contacting the surface produces the electric current to the skin. The epidermis is spared by applying a cooling spray which protects it from the heating effect of the device. The dermis is then heated uniformly and volumetrically, sparing the epidermis. Partial collagen denaturation occurs as a result of this heating, which leads to collagen contraction and thickening. Some shrinkage of the collagen framework may occur immediately due to fibril denaturation. More tightening follows due to a natural inflammatory wound healing response that triggers new collagen formation and further skin contraction. The collagen-based fibrous septa that separate fat lobules in the subcutaneous tissue are also preferentially heated, leading to further collagen denaturation and contraction of the subcutaneous tissue and accounting for the immediate tightening and lifting effect on the skin. The understanding of the clinical and histologic changes induced by monopolar RF advanced through the work of Prof Moawad and his colleagues. At MSI, we treated participants with Glogau classification I to II facial wrinkles and reported increases in mean collagen types I and III as well as newly synthesized collagen. We also observed higher levels of mean collagen and a lower level of mean elastin at three months post-treatment than immediately post-treatment, which attributed to continued dermal remodeling. Participants demonstrated statistically significant improvements in skin tightening. The FDA initially approved monopolar RF devices to treat periorbital wrinkles. Since then, they have been used to treat laxity of the forehead, cheeks, nasolabial folds, marionette, lines, jawline, and neck.

Aside from wrinkles reduction, successful treatment of moderate to severe cystic acne, acne scarring, and cellulite have been reported. The use of more critical, faster tips, lower energy levels, and multiple passes have diminished associated pain but not eliminated it. The low-level multiple passes approach necessitates 4-6 sessions every one to two weeks. The procedure can be repeated everyone year as needed to keep up the results. The best results are seen in patients with mild to moderate wrinkling with early signs of aging. Patients who have prominent skin folds and laxity would probably benefit from more invasive procedures. Although the results of RF are not as dramatic as a facelift, over 90% of patients obtain noticeable tightening of the treated areas, and it never looks “pulled.” Contraindications include implantable medical devices such as pacemakers and defibrillators and active dermatologic conditions like collagen vascular disease and autoimmune diseases. Everybody is the right candidate for RF, but it is of particular significance to those who do not like invasive surgical intervention and are still young for surgery.

Bipolar RF (ELOS) and (FACES)

The main difference between bipolar and monopolar RF is the configuration. The monopolar RF devices have one active electrode placed on the skin and a grounding electrode. The bipolar configuration consists of two active electrodes set a short distance apart, overlying the intended treatment area. The current flows between the two electrodes. The depth of penetration is approximately half the distance between the two electrodes. The major limitation of this configuration is the depth of penetration. The monopolar device achieves high penetration of the emitted current, which serves its main advantage and its major drawback associated with pain. The bipolar configuration is not as penetrating but provides a more controlled distribution of energy and less pain. Bipolar RF has been employed for a lengthy and continually expanding list of indications, including skin laxity, wrinkles, vascular lesions, dyschromia, cellulite, and body tightening. Bipolar technologies continue to expand the reach and effectiveness of novel RF devices. This technology recently was described for the treatment of xanthelasma palpebrarum, including the effective treatment of lesions close to the eyes. Another novel use of bipolar RF is to eliminate glabellar furrows via the percutaneous ablation of efferent nerves innervating the corrugator and procerus muscles.

Electro-optical Synergy (ELOS)/ E-Light

Electro-Optical Synergy (ELOS) or, in short, E-light technology combines electrical (conducted radiofrequency (RF)) and optical (laser/light) energies. ELOS theory is based on the optical component (laser or IPL) heating the hair shaft, which then is thought to concentrate the bipolar RF energy to the surrounding hair follicle. The general idea of this method is to reduce the intensity – and thus, the potential side-effects of optical energy by combining it with bipolar radiofrequency (RF), which is supposed to concentrate where the light has selectively heated the target. Based on this combination, low Fluence is needed for the optical component, suggesting it might be well tolerated in all Fitzpatrick skin phototypes and potentially effective in removing lightly pigmented hair. Therefore, lower levels of energy of the light and RF component are needed to produce the desired effect with fewer side effects. Combining the infrared laser at 900 nm and bipolar radiofrequency (RF) and IPL (500-1200 nm) with bipolar RF has been evaluated systematically to reduce all aspects of photodamage and wrinkles. The combination of RF with diode laser and pulsed light has been shown to induce tissue contraction and effects on laxity, lines, and other aspects of photodamage. However, a significant drawback of this therapy is that it requires many treatments at 2- to3-week intervals, which may ultimately achieve only mild to moderate improvement. The most widely used ELOS systems use intense pulsed light (IPL), a diode laser, or infrared light. Another ELOS device (Vela Smooth; Syneron) uses a combination of infrared light (700–2,000 nm), RF energy, and suction with mechanical massage to treat cellulite. There also have been advances in the treatment of unwanted veins utilizing bipolar RF.

Functional aspiration controlled electro-heat stimulation (FACES)

The FACES system uses a vacuüm system in combination with bipolar RF. The vacuüm is used to fold the skin to a predetermined depth, which allows for closer alignment and deeper penetration with the RF energy than with traditional monopolar and bipolar devices. The volume of treated tissue is limited to that located between the electrodes in the special vacuüm tip, so lower energy levels can be used to meet the energy density needed to reach and affect the chosen skin layers, leading to greater efficacy, less pain, and lower incidence of side effects. FACES are used to treat facial laxity, rhytid reduction, vascular and pigmented lesions, acne, acne scarring, hair removal, and cellulite. The significant limitations of the bipolar RF devices seem to be the depth of penetration. A combination of light devices has been used to overcome this limitation. Although the combination systems are better tolerated than the monopolar RF systems, I may use topical anesthetic creams to ease any associated pain at the physician’s discretion. Modest results have been reported about the efficacy of the ELOS systems for and FACES in skin rejuvenation, acne, scars, and cellulite.

Tripolar RF

Tripolar RF expands on the bipolar configuration, employing three or more electrodes to deliver current to skin tissue. The TriPollar RF device (Regen) can simultaneously heat superficial and deep skin layers by providing a focused current to the skin. The safety and efficacy of using the TriPollar RF device for striae distensae, circumference reduction, cellulite treatment, and localized fat were successful. The procedure is almost painless. Newer radiofrequency technologies are developing to promote the degree of skin tightening in fewer treatments. The most recent is the combination of multipolar RF and magnetic pulses. Although RF increases collagen and elastin synthesis, the magnetic pulse field should increase the production of fibroblast growth factor b2. The benefits of this platform are lower overall energy, increased safety, and no need for pretreatment preparation and topical cooling agents.

Unipolar RF

Unipolar RF differs from monopolar RF in that it does not deliver an electric current to the skin. Instead, it uses high-frequency electromagnetic radiation at 40 MHz (Accent RF System) to induce rotational oscillations in water molecules and ultimately produce heat. This heat is dissipated to surrounding tissues and can reach a depth of 15–20 mm. The profoundly penetrating technology has been used to treat conditions caused by irregularities of the fibrous septa in the dermis, specifically cellulite. RF-induced contraction between the dermis and Camper’s fascia may explain the first skin tightening effect, but its longer- the lasting impact is due to dermal fibrosis. The unipolar model targets the deep dermis and subcutaneous junction because the bipolar way targets the papillary and mid dermis, improving laxity and fine lines through a common approach. The Accent™ XL, an updated version of the device, is now available. Several treatment tips have become available for this device, including a UniLarge tip, an eye tip, and a cellulite-massaging tip.

Fractional Radiofrequency (FRF)

Fractional RF is a newer nonablative approach. There are two ways to deliver fractional RF. Whereas some devices (Matrix RF device) use electrodes, others use an array of microneedles arranged in pairs between which bipolar RF energy is delivered (ePrime system).  The fractionally distributed energy creates zones of affected skin adjacent to unaffected areas. The treated areas have resulting heat damage in the deep dermal collagen, which stimulates wound healing, dermal remodeling, and new collagen, elastin, and hyaluronic acid formation. The unaffected areas in between affected areas initially maintain skin integrity but, in the long term, serve as a reservoir of cells that promote and accelerate wound healing. Microneedle Fractional RF also showed improvement of acne scars and large facial pores with fewer adverse events than fractional lasers. However, moderate to severe acne scars showing superficial irregularities need multiple microneedles fractional RF treatment sessions for helpful improvement. A new device has been developed that combines fractionated optical energy with a 915-nm diode coupled with a fractionated bipolar RF. This integrated system targets the epidermis and superficial dermis. The RF component synergistically uses less energy to heat the collagen in the deep dermis and stimulate new collagen formation and contraction (Matrix eLaser). This device has been associated with significant improvement in acne scarring, texture, and pigmentation. It appears that FRF devices are a safe, tolerable, and effective modality for wrinkles and facial laxity reduction. The most common side effects are erythema and edema, which are transient, and patient discomfort does not seem to be a significant disadvantage. A topical anesthetic cream may be used before treatment to lower pain.

Radiofrequency and Skin Tightening, Fat Reduction and Cellulite

Since the dawn of civilization, achieving a more aesthetically ideal body shape by artificial means has been a cultural desire. Throughout history, many methods, from bondage to surgery, have been employed. However, growing consumer demand for body shaping without surgery and its severe complications has produced an emerging array of highly innovative non-invasive technologies in the past few years. One of the newest fat reduction technologies is radiofrequency, which delivers energy to the areas of fat by driving controlled heat deep within the fat cells to destroy them. A controlled internal electric field perpendicular to the skin–fat interface is selective in heating fat. It can induce lethal heat damage to subcutaneous adipose tissues while sparing overlying and underlying tissues. RF technology offers unique advantages for non-invasive selective heating of relatively large volumes of subcutaneous adipose tissue. The collagen-based fibrous septa are also preferentially heated, leading to further collagen denaturation and immediate contraction. Delayed fat cell Death leading to fat reduction, and new collagen deposition leads to skin tightening and lifting. While these new, non-invasive technologies are suitable, they are not as effective in removing fat as an invasive procedure like liposuction,” said Prof Moawad. “Radiofrequency is a very versatile procedure that can be used on any area of the body – from large areas like the abdomen to minimal areas such as the chin – with the same degree of success,” said Prof Moawad. “For people who are not considered overweight but have stubborn pockets of unwanted fat that are not responding to diet and exercise, radiofrequency is a good option.” Another benefit of radiofrequency is reducing fat and tightening the skin by directing energy to target collagen. For example, a patient with flabby upper arms may have more loose skin than fat in this area. In this instance, Prof Moawad might use radiofrequency to tighten the skin first and then remove excess fat. However, if he determines that there is primarily fat in an area, he would remove the fat first and then tighten the skin afterward.

Heat treatment using optical energy for various types of dermatologic problems has become very popular over the past 20 years. Light-based therapies with lasers and intense pulse light (IPL) technologies have been increasingly used in aesthetic medicine for epilation, removal of vascular and pigmented lesions, reduction of fine wrinkles, and acne treatment. Although useful for a broad range of dermatological indications, limitations also have been realized with light-based therapies. One of the main limitations is that optical energy must penetrate the epidermis to reach the depth of the targeted site. Melanin chromophores absorb optical energy in the epidermis and hair shafts and hemoglobin in the blood. In photo epilation, light-colored hair is challenging to remove because it has low melanin levels and, therefore, may not absorb enough energy to achieve heat destruction of the hair follicle.

Conversely, high pigmentation of the epidermis also poses a problem because it may absorb too much power, potentially causing adverse effects such as burns and hyperpigmentation. Wrinkles respond poorly to treatment with optical energy because collagen fibers do not contain chromophores. These limitations have stimulated investigators to look for new forms of energy that satisfy the principle of selective thermolysis but are devoid of the main disadvantage of optical energy for dermatological applications; that is, a strong interdependence between treatment efficacy/safety and chromophore levels in the epidermis.
The use of radiofrequency (RF) for selective electro-thermolysis has been found to produce a highly efficient heat effect on biological tissue. Unlike optical energy, RF energy depends on the tissue’s electrical properties and not on the concentration of chromophores in the skin for selective heat destruction of targeted sites.

Types of Radiofrequency (RF) Technologies?

Radiofrequency devices can be classified into several configurations based on how the electrical current passes through the tissue. The first type introduced was monopolar RF, which applies energy to tissue via a single electrode tip and a grounding plate. Bipolar RF applies heat to the tissue via 2 points on the tip of a single probe, and penetration depth is estimated at half the distance between the electrodes. Tripolar RF devices were recently introduced; this technology simultaneously uses multiple electrode configurations to heat superficial and deep skin layers. Fractional RF also is a novel technology in which bipolar RF energy is delivered via a minimally invasive approach using a microneedle electrode assembly. This technology generates discrete heat zones of treated tissue to the depth of the deep dermis with fractional sparing of the epidermis and adnexa, thereby inducing a rapid and vigorous wound-healing response along with sustained dermal remodeling and profound new collagen formation.

Monopolar Radiofrequency

Monopolar systems deliver current using one electrode that contacts the skin and another that acts as a grounding pad. The electrode contacting the surface produces the electric current to the skin. The epidermis is spared by applying a cooling spray which protects it from the heating effect of the device. The dermis is then heated uniformly and volumetrically, sparing the epidermis. Partial collagen denaturation occurs as a result of this heating, which leads to collagen contraction and thickening. Some shrinkage of the collagen framework may occur immediately due to fibril denaturation. More tightening follows due to a natural inflammatory wound healing response that triggers new collagen formation and further skin contraction. The collagen-based fibrous septa that separate fat lobules in the subcutaneous tissue are also preferentially heated, leading to further collagen denaturation and contraction of the subcutaneous tissue and accounting for the immediate tightening and lifting effect on the skin. The understanding of the clinical and histologic changes induced by monopolar RF advanced through the work of Prof Moawad and his colleagues. At MSI, we treated participants with Glogau classification I to II facial wrinkles and reported increases in mean collagen types I and III as well as newly synthesized collagen. We also observed higher levels of mean collagen and a lower level of mean elastin at three months post-treatment than immediately post-treatment, which attributed to continued dermal remodeling. Participants demonstrated statistically significant improvements in skin tightening. The FDA initially approved monopolar RF devices to treat periorbital wrinkles. Since then, they have been used to treat laxity of the forehead, cheeks, nasolabial folds, marionette, lines, jawline, and neck.

Aside from wrinkles reduction, successful treatment of moderate to severe cystic acne, acne scarring, and cellulite have been reported. The use of more critical, faster tips, lower energy levels, and multiple passes have diminished associated pain but not eliminated it. The low-level multiple passes approach necessitates 4-6 sessions every one to two weeks. The procedure can be repeated everyone year as needed to keep up the results. The best results are seen in patients with mild to moderate wrinkling with early signs of aging. Patients who have prominent skin folds and laxity would probably benefit from more invasive procedures. Although the results of RF are not as dramatic as a facelift, over 90% of patients obtain noticeable tightening of the treated areas, and it never looks “pulled.” Contraindications include implantable medical devices such as pacemakers and defibrillators and active dermatologic conditions like collagen vascular disease and autoimmune diseases. Everybody is the right candidate for RF, but it is of particular significance to those who do not like invasive surgical intervention and are still young for surgery.

Bipolar RF (ELOS) and (FACES)

The main difference between bipolar and monopolar RF is the configuration. The monopolar RF devices have one active electrode placed on the skin and a grounding electrode. The bipolar configuration consists of two active electrodes set a short distance apart, overlying the intended treatment area. The current flows between the two electrodes. The depth of penetration is approximately half the distance between the two electrodes. The major limitation of this configuration is the depth of penetration. The monopolar device achieves high penetration of the emitted current, which serves its main advantage and its major drawback associated with pain. The bipolar configuration is not as penetrating but provides a more controlled distribution of energy and less pain. Bipolar RF has been employed for a lengthy and continually expanding list of indications, including skin laxity, wrinkles, vascular lesions, dyschromia, cellulite, and body tightening. Bipolar technologies continue to expand the reach and effectiveness of novel RF devices. This technology recently was described for the treatment of xanthelasma palpebrarum, including the effective treatment of lesions close to the eyes. Another novel use of bipolar RF is to eliminate glabellar furrows via the percutaneous ablation of efferent nerves innervating the corrugator and procerus muscles.

Electro-optical Synergy (ELOS)/ E-Light

Electro-Optical Synergy (ELOS) or, in short, E-light technology combines electrical (conducted radiofrequency (RF)) and optical (laser/light) energies. ELOS theory is based on the optical component (laser or IPL) heating the hair shaft, which then is thought to concentrate the bipolar RF energy to the surrounding hair follicle. The general idea of this method is to reduce the intensity – and thus, the potential side-effects of optical energy by combining it with bipolar radiofrequency (RF), which is supposed to concentrate where the light has selectively heated the target. Based on this combination, low Fluence is needed for the optical component, suggesting it might be well tolerated in all Fitzpatrick skin phototypes and potentially effective in removing lightly pigmented hair. Therefore, lower levels of energy of the light and RF component are needed to produce the desired effect with fewer side effects. Combining the infrared laser at 900 nm and bipolar radiofrequency (RF) and IPL (500-1200 nm) with bipolar RF has been evaluated systematically to reduce all aspects of photodamage and wrinkles. The combination of RF with diode laser and pulsed light has been shown to induce tissue contraction and effects on laxity, lines, and other aspects of photodamage. However, a significant drawback of this therapy is that it requires many treatments at 2- to3-week intervals, which may ultimately achieve only mild to moderate improvement. The most widely used ELOS systems use intense pulsed light (IPL), a diode laser, or infrared light. Another ELOS device (Vela Smooth; Syneron) uses a combination of infrared light (700–2,000 nm), RF energy, and suction with mechanical massage to treat cellulite. There also have been advances in the treatment of unwanted veins utilizing bipolar RF.

Functional aspiration controlled electro-heat stimulation (FACES)

The FACES system uses a vacuüm system in combination with bipolar RF. The vacuüm is used to fold the skin to a predetermined depth, which allows for closer alignment and deeper penetration with the RF energy than with traditional monopolar and bipolar devices. The volume of treated tissue is limited to that located between the electrodes in the special vacuüm tip, so lower energy levels can be used to meet the energy density needed to reach and affect the chosen skin layers, leading to greater efficacy, less pain, and lower incidence of side effects. FACES are used to treat facial laxity, rhytid reduction, vascular and pigmented lesions, acne, acne scarring, hair removal, and cellulite. The significant limitations of the bipolar RF devices seem to be the depth of penetration. A combination of light devices has been used to overcome this limitation. Although the combination systems are better tolerated than the monopolar RF systems, I may use topical anesthetic creams to ease any associated pain at the physician’s discretion. Modest results have been reported about the efficacy of the ELOS systems for and FACES in skin rejuvenation, acne, scars, and cellulite.

Tripolar RF

Tripolar RF expands on the bipolar configuration, employing three or more electrodes to deliver current to skin tissue. The TriPollar RF device (Regen) can simultaneously heat superficial and deep skin layers by providing a focused current to the skin. The safety and efficacy of using the TriPollar RF device for striae distensae, circumference reduction, cellulite treatment, and localized fat were successful. The procedure is almost painless. Newer radiofrequency technologies are developing to promote the degree of skin tightening in fewer treatments. The most recent is the combination of multipolar RF and magnetic pulses. Although RF increases collagen and elastin synthesis, the magnetic pulse field should increase the production of fibroblast growth factor b2. The benefits of this platform are lower overall energy, increased safety, and no need for pretreatment preparation and topical cooling agents.

Unipolar RF

Unipolar RF differs from monopolar RF in that it does not deliver an electric current to the skin. Instead, it uses high-frequency electromagnetic radiation at 40 MHz (Accent RF System) to induce rotational oscillations in water molecules and ultimately produce heat. This heat is dissipated to surrounding tissues and can reach a depth of 15–20 mm. The profoundly penetrating technology has been used to treat conditions caused by irregularities of the fibrous septa in the dermis, specifically cellulite. RF-induced contraction between the dermis and Camper’s fascia may explain the first skin tightening effect, but its longer- the lasting impact is due to dermal fibrosis. The unipolar model targets the deep dermis and subcutaneous junction because the bipolar way targets the papillary and mid dermis, improving laxity and fine lines through a common approach. The Accent™ XL, an updated version of the device, is now available. Several treatment tips have become available for this device, including a UniLarge tip, an eye tip, and a cellulite-massaging tip.

Fractional Radiofrequency (FRF)

Fractional RF is a newer nonablative approach. There are two ways to deliver fractional RF. Whereas some devices (Matrix RF device) use electrodes, others use an array of microneedles arranged in pairs between which bipolar RF energy is delivered (ePrime system).  The fractionally distributed energy creates zones of affected skin adjacent to unaffected areas. The treated areas have resulting heat damage in the deep dermal collagen, which stimulates wound healing, dermal remodeling, and new collagen, elastin, and hyaluronic acid formation. The unaffected areas in between affected areas initially maintain skin integrity but, in the long term, serve as a reservoir of cells that promote and accelerate wound healing. Microneedle Fractional RF also showed improvement of acne scars and large facial pores with fewer adverse events than fractional lasers. However, moderate to severe acne scars showing superficial irregularities need multiple microneedles fractional RF treatment sessions for helpful improvement. A new device has been developed that combines fractionated optical energy with a 915-nm diode coupled with a fractionated bipolar RF. This integrated system targets the epidermis and superficial dermis. The RF component synergistically uses less energy to heat the collagen in the deep dermis and stimulate new collagen formation and contraction (Matrix eLaser). This device has been associated with significant improvement in acne scarring, texture, and pigmentation. It appears that FRF devices are a safe, tolerable, and effective modality for wrinkles and facial laxity reduction. The most common side effects are erythema and edema, which are transient, and patient discomfort does not seem to be a significant disadvantage. A topical anesthetic cream may be used before treatment to lower pain.

Radiofrequency and Skin Tightening, Fat Reduction and Cellulite

Since the dawn of civilization, achieving a more aesthetically ideal body shape by artificial means has been a cultural desire. Throughout history, many methods, from bondage to surgery, have been employed. However, growing consumer demand for body shaping without surgery and its severe complications has produced an emerging array of highly innovative non-invasive technologies in the past few years. One of the newest fat reduction technologies is radiofrequency, which delivers energy to the areas of fat by driving controlled heat deep within the fat cells to destroy them. A controlled internal electric field perpendicular to the skin–fat interface is selective in heating fat. It can induce lethal heat damage to subcutaneous adipose tissues while sparing overlying and underlying tissues. RF technology offers unique advantages for non-invasive selective heating of relatively large volumes of subcutaneous adipose tissue. The collagen-based fibrous septa are also preferentially heated, leading to further collagen denaturation and immediate contraction. Delayed fat cell Death leading to fat reduction, and new collagen deposition leads to skin tightening and lifting. While these new, non-invasive technologies are suitable, they are not as effective in removing fat as an invasive procedure like liposuction,” said Prof Moawad. “Radiofrequency is a very versatile procedure that can be used on any area of the body – from large areas like the abdomen to minimal areas such as the chin – with the same degree of success,” said Prof Moawad. “For people who are not considered overweight but have stubborn pockets of unwanted fat that are not responding to diet and exercise, radiofrequency is a good option.” Another benefit of radiofrequency is reducing fat and tightening the skin by directing energy to target collagen. For example, a patient with flabby upper arms may have more loose skin than fat in this area. In this instance, Prof Moawad might use radiofrequency to tighten the skin first and then remove excess fat. However, if he determines that there is primarily fat in an area, he would remove the fat first and then tighten the skin afterward.

Radiofrequency-assisted liposuction (RFAL)

You can divide the body contouring world into non-invasive and invasive. You can also subdivide invasive and non-invasive into focal body contouring reductions and generalized slimming. Liposuction, which remains the gold standard in focal and sequential multi-focal body contouring, uses small suction cannulas, with or without tumescent anesthesia, with or without lasers, ultrasound, propulsive jet sprays, or radiofrequency energy to actively aspirate fat from localized areas of fat accumulation. Liposuction is still the most successful way to quickly, safely, and effectively create the contouring figure you want. However, there are some risks, such as recovery time, swelling, and bruises, that lead to the growth of non-surgical, non-invasive body contouring. Laxity can result from chronological or photoaging and changes in body dimensions during pregnancy or weight loss. The result is loose and sagging skin. The successful cosmetic procedures for addressing body contouring and tightening are surgical, such as abdominoplasty, breast lift, or arms lift. While surgical correction undoubtedly produces the most definitive results, it also requires significant recovery time for patients and carries inherent risks. Together with today’s cosmetic patients’ active lifestyles and wish for results with minimal potential sequelae, these factors have procreated the development of many new non-invasive body-contouring devices to mitigate skin laxity and cut body circumference, such as radiofrequency.

Furthermore, tumescent liposuction-assisted power, laser, ultrasound, or radiofrequency has emerged to give skin tightening and ease the process of body contouring and fat aspiration with the hope of dropping the need for more invasive surgical intervention. RFAL is the newest addition to the liposuction family and can be found only in the BodyTite device. RFAL uses RF energy to heat the fatty tissue, skin, and subdermal matrix. RFAL technology uses two electrodes— one external and one internal, connected by a handpiece—which creates a heat profile. The handpiece controls treatment depth from 5–50mm, allowing uniform treatment over not only the treatment area but also through the thickness of the subcutaneous tissue. This uniform heating is a basis for safe and effective tissue tightening. First contraction studies show a next linear contraction of 15% and long-term linear contraction of 30-40% over 12 weeks, enhancing the contour results in patients with slight or compromised laxity.

Radiofrequency Skin Tightening Helps Acne and Acne Scars

Acne vulgaris usually need a regimen of systemic and/or topical medications, given for several months or even years, and often requires multiple visits to the physician’s office, the laboratory, etc. This results in a loss of time at school and considerable expense. Side effects from medications and the constant need to use alternative drugs when there is no response to medical treatment are possible. Why does heat help these patients? Prof Moawad feels that it may have to do with inhibition of sebaceous gland activity. As seen in many of these patients, excessive oiliness of the skin is helped by the treatment. Sebaceous glands seem to be decreased in volume after a few weeks after treatment with this device. This reverts to normal after a few months. Nonablative radiofrequency appears to be a new safe and effective treatment alternative for moderate to severe acne vulgaris. A dual beneficial effect from the treatment was noticed: a decrease in acne activity plus an improvement in the underlying scarring. One session appears to be safe and effective because multiple sessions may prove beneficial to cases that did not respond to the first session after a 4-month wait.

Radiofrequency helps Permanent Hair Reduction.

The effective removal of unwanted hair using optical energy has been mainly limited to black and dark and medium tones of brown hair. Treatment of light-colored hair has been challenging because of the limited concentration of melanin chromophores in hair follicles. In addition, safety is a concern in dark skin types, who have an increased risk of blistering and dyschromia, even with more extended pulse lasers. It would make sense that the combination of low levels of optical energy and electrical conducted RF current, the latter of which is not dependent on melanin for heat absorption may effectively and safely remove hair, including light-colored hair, for all skin types. White hair is a huge distraction and an alarming fact that signifies you are old. Thermolysis (diathermy) is performed using high-frequency alternating current at low voltage to healthy destroy or epilate hair follicles – a process termed electro-epilation. Thermolysis has a somewhat higher risk of scarring and pain, although modern electro-epilation devices have precise automatic timers and insulated probes that cut the chances of scarring. Moawad Skin Institute (MSI) has the latest Radiofrequency technology for white hair removal treatment. The process can be uncomfortable, but local anesthetic creams can help. Thermolysis is more effective on anagen hairs; therefore, shaving within a few days before electrolysis significantly increases its efficacy because it ensures that only growing anagen hairs are epilated. This is particularly important during the first treatment of an area because as many as 60% of the hairs may be in telogen, which is challenging to eradicate permanently. Hair regrowth rates following treatment are highly variable and range from 15–50%. The wide variation has been attributed to the differences in equipment used and the operator’s skill. Multiple treatment sessions are necessary to avoid the simultaneous treatment of adjacent hair follicles (within 3–4 mm of each other) to cut unnecessary heat skin injury.

Fractional Radiofrequency Helps Sweat Reduction

Proudly at MSI, a newer bipolar RF device are effective in reducing the amount of sweating.  New bipolar RF devices can destroy the eccrine glands by thermolysis at the deep dermis and subcutis interface while minimizing damage to the surrounding tissue. Fractional radiofrequency treatment appears to be a new safe, and effective treatment alternative for moderate to severe primary axillary hyperhidrosis. Prof Moawad suggests It is repeated sessions of FR be considered to achieve a complete response.

Conclusion

Radiofrequency technology continues to advance rapidly, providing dermatologists with an expanding array of skin rejuvenation techniques that result in few adverse effects and minimal downtime for patients. Radiofrequency treatments allow physicians to augment targeted tissue layers while sparing melanocytes and the cutaneous surface, preventing dyspigmentation and delayed wound healing. RF technology is a new and expanding sector of cosmetic dermatology. Future developments likely will continue to enhance the therapeutic index of RF by tailoring treatment to the individual patient, combining RF with other treatment modalities, and exploring and expanding indications for therapy.