Skin tightening with a
combined unipolar and
bipolar radiofrequency
device
Monopolar radiofrequency
(RF) devices are well
established treatment
modalities for tightening
facial skin. A
60-year-old woman presented
with a desire to tighten the
lax skin and improve the
appearance of both upper
arms. A combination unipolar
and bipolar RF device may
provide volume reduction as
well as skin tightening in
the upper arm.
Introduction
A variety of clinical
studies have documented the
ability of capacitively
coupled monopolar
radiofrequency (RF) energy
(ThermaCool TC, Thermage,
Inc., Hayward, CA) to
noninvasively tighten facial
skin by volumetric heating
of the dermis. Other
tissue-tightening RF devices
are combinations in which
bipolar RF energy is
combined with diode laser
energy (1,2) or with both
diode laser and intense
pulsed light energies. (3)
The Accent (Alma Lasers,
Inc, Ft. Lauderdale, FL) RF
system is designed for
continuous skin contact
using 2 hand-pieces: the
unipolar to deliver RF
energy to the subcutaneous
adipose tissue for
volumetric heating and the
bipolar to deliver RF energy
to the dermis for
nonvolumetric heating. This
case study compares the
efficacies of the ThermaCool
and the Accent in the
treatment of skin laxity in
the upper arm.
Case Report
A 60-year-old woman
(Fitzpatrick skin type III)
presented with a desire to
tighten the lax skin and
improve the appearance of
both upper arms. The patient
had a history of breast
cancer 4 years earlier and
had been treated by
lumpectomy.
The right arm was treated
with the ThermaCool device.
Exposure duration and
cooling during each exposure
period were controlled by a
3-[cm.sup.2] treatment tip.
The patient's upper arm
received 1200 pulses.
Treatment settings were
adjusted on the basis of
patient feedback on
discomfort (0-4; 4 =
intolerable). Settings were
changed when the discomfort
level reached 2.5. Settings
were 351.5 on the inner arm
and 353.5 to 354.0 on the
outer arm. The patient
received a minimum of 6
passes on the inner arm and
a minimum of three passes on
the outer arm.
Due to the lengthy 2-hour
duration of ThermaCool
treatment, the author
suggested that the left arm
receive a single treatment
with the Accent RF system.
The patient was informed
that the Accent RF system
would require multiple
treatments to achieve
results. The patient
consented to treatment with
the ThermaCool on her right
arm and a 30-minute
treatment with the Accent on
her left arm to see if the 2
devices would produce
different results.
Using the unipolar
(Accent) handpiece, the
author treated the left arm
to a maximum temperature of
42.5[degrees]C. The
electrode tip was cooled
during treatment to prevent
thermal damage to the
epidermis. (4) Three
additional passes were done
to maintain the treated area
at the therapeutic
temperature, as recommended
by the manufacturer. The
patient received no
anesthesia, pretreatment
care, or post-treatment care
with either RF device.
Approximately 2 months
later, the patient
returned for evaluation of
both upper arms. The skin of
the ThermaCool-treated arm
showed improvement in
texture and smoothness as
well as reduced wrinkling,
especially on the inner
part. The Accent-treated arm
showed no differences. The
patient was reminded that to
compare the devices, she
needed to have additional
Accent treatments at 2-week
intervals because the
ThermaCool skin-tightening
protocol calls for a single
treatment with evaluation 4
to 6 months after treatment
and the Accent protocol
calls for multiple
treatments.
After the initial
treatment session, the
patient had 5 additional
treatments at 2-week
intervals with the Accent on
the left arm (Figure 1) and
no additional ThermaCool
treatments on the right arm
(Figure 2). On the seventh
visit, the patient had had 6
Accent treatments on her
left arm and a single
ThermaCool treatment on her
right arm 5 months earlier.
The patient was pleased
because her clothes no
longer felt tight on her
left arm. Although skin
texture had improved in both
upper arms, the skin of the
Accent-treated arm was
tighter and firmer (Figure
1). Photographs were taken
of both arms during this
visit and before the left
arm received the seventh
Accent treatment.
The patient continued to
receive Accent treatments on
the left arm at 2-week
intervals while the right
arm remained untreated.
These Accent treatments were
given with a combination of
the unipolar and bipolar
handpieces. After a total of
9 Accent treatments of her
left arm, the patient asked
the author to treat her
right upper arm with the
Accent device. The right
ThermaCool-treated upper arm
after 2 Accent treatments is
shown in Figure 3. The
patient was very satisfied
with the improved tightness
and firmness of her right
upper arm. The patient
commented that after her
ThermaCool-treated arm
received 2 additional Accent
treatments, her clothes fit
better on that arm as well.
No adverse effects were
observed with either RF
device.
Discussion
For ThermaCool skin
tightening, patients
typically receive a single
treatment that requires a
treatment tip which cannot
be reused. Additional
treatments to improve
results may be cost
prohibitive to both the
patient and clinician.
Though multiple treatments
are necessary for good
results, the Accent does not
require the purchase of a
disposable tip, the
treatments are shorter in
duration, and improvement is
noticeable after 2 or 3
treatments. A crucial step
in gaining favorable results
is slowly heating the skin
to the patient's pain
threshold, usually between
40[degrees]C and
44[degrees]C, and
maintaining this temperature
range for approximately 2
minutes, then moving to
another area.
For this patient, the
Accent may be the device
of choice because (1) the
patient's clothes fit better
on the Accent-treated arm
than on the
ThermaCool-treated arm and
(2) the patient's clothes
fit better on the
ThermaCool-treated arm only
after several additional
treatments with the Accent.
The RF energy of the
ThermaCool went only to the
dermal layer of this woman's
skin; therefore, the
ThermaCool-induced changes
were superficial in a
patient whose primary
cosmetic problem was excess
volume rather than
wrinkling. These
observations suggest that
when patients require both
tissue tightening and volume
reduction in a nonfacial
area, the Accent may be the
treatment of choice because
the RF energy penetrates
deeper.
When the ThermaCool is
used, tissue tightening
occurs as a result of
immediate collagen
contraction and
formation of new collagen
months later. (5) An
alternating current (6 MHz)
causes charged particles in
tissue to move, and this
molecular motion produces
heat. (6) Heat-induced
denaturation of collagen
typically occurs at
65[degrees]C. Multiple
passes at moderate settings
rather than single passes at
higher settings have been
suggested to avoid irregular
contours and to reduce pain
and adverse effects. (7,8)
The epidermis is protected
by contact cooling before,
during, and after treatment.
(9) The use of minimal
anesthesia or pain blocking
is also recommended so that
patient feedback can be used
as a guide to treatment
settings. (8,10)
The results of this case
study raise the question of
the volume (fat) reduction
by these devices. Most
tissue-tightening studies of
the ThermaCool have been
done on the face, neck, or
both. The depth of heating
depends on the geometry of
the treatment tip, (11)
available in 1-, 1.5-, and
3-[cm.sup.2] sizes. (12) To
the author's knowledge,
although RF energy delivered
by the ThermaCool device may
reach the subcutaneous
layer, volume (fat)
reduction has not been
studied extensively. One
study suggested that stacked
pulses applied to the
submental region reduced fat
content in that area. (13)
Hardaway and colleagues (14)
suggested that "depending on
cooling times, RF power, and
electrode type, selective
dermal heating can be
achieved at levels as
superficial as the papillary
dermis and as deep as
subcutaneous fat."
Ruiz-Esparza and colleagues
(15) stated that a prototype
of the ThermaCool "delivers
heat to the dermis and
beyond." In an analysis of
complication rates of the
ThermaCool, Narins and
colleagues (10) reported
that overheating of deeper
tissue may damage fat cells
and over tighten fibrous
septae, resulting in fat
loss, deep fibrous scarring,
and irregular skin-surface
contours that may be
corrected by subcision of
fibrous tissue with
microinjections of
autologous fat.
In the Accent system, RF
energy is delivered through
2 handpiece applicators,
one for unipolar energy and
the other for bipolar
energy. An alternating
current of 40 MHz is
generated, considerably
higher than the 6-MHz
current of the ThermaCool,
resulting in more heat
generated due to the motion
of charged particles. The
energy from the unipolar
handpiece penetrates 20 mm
to the subcutaneous adipose
tissue whereas the bipolar
handpiece is designed to
penetrate 2 to 6 mm to
stimulate structural changes
in the dermis. (4) Emilia
del Pino and colleagues (4)
showed that 68% of 26
patients treated twice with
Accent RF energy on the
buttocks and thighs achieved
a 20% volumetric contraction
effect, indicating that RF
energy affects the
connective tissue of the
subcutaneous adipose tissue.
The authors suggest that
this effect would probably
occur in other body areas as
well.
The patient in the
present study was treated in
the left upper arm first
with the unipolar handpiece
for the first 6 treatments,
and with the combination of
unipolar and bipolar
handpieces for the last 3
treatments. The
post-treatment increase in
tightening, firmness, and
texture of the skin is
consistent with the
hypothesis of Emilia del
Pino and colleagues, which
states that unipolar RF
energy stimulates
contraction of collagen
fibers by heating
subcutaneous adipose tissue.
(4) Additional skin
tightening in the patient of
the present study probably
occurred as a result of
local bipolar RF-induced
dermal heating and
subsequent contraction of
collagen.
This study raises several
questions: (1) How do
the Accent and ThermaCool
devices affect fat volume in
nonfacial areas? (2) What
effect will additional
treatments by either or both
devices have on volume
reduction? (3) What
mechanisms are responsible
for the differences in
volume reduction by both
devices?
Conclusion
On the upper arm, the Accent
RF device provides
improvements in skin laxity,
texture, and firmness at
least comparable to that of
the ThermaCool and without
adverse effects. The Accent
treatments also provide
volume reduction in the left
arm by a mechanism not yet
determined. Studies of the
efficacy and safety of the
Accent device with more
patients and on other body
areas are warranted.
Disclosure
Dr. Mayoral received no
funding for this study. She
receives research support
from and is a funded speaker
for Thermage, Inc.
References
1. Doshi SN, Alster TS.
Combination radiofrequency
and diode laser for
treatment of facial rhytides
and skin laxity. J Cosmet
Laser Ther. 2005;7:11-15.
2. Sadick N,
Alexiades-Armenakis M,
Bitter P Jr., Hruza G,
Mulholland RS. Enhanced
full-face skin rejuvenation
using synchronous intense
pulsed optical and conducted
bipolar radiofrequency
energy (ELOS): introducing
selective
radiophotothermolysis. J
Drugs Dermatol.
2005;4:181-186.
3. Alexiades-Armenakas M.
Rhytides, laxity, and
photoaging treated with a
combination of
radiofrequency, diode laser,
and pulsed light and
assessed with a
comprehensive grading scale.
J Drugs Dermatol.
2006;5:731-738.
4. Emilia del Pino M, Rosado
RH, Azuela A, et al. Effect
of controlled volumetric
tissue heating with
radiofrequency on cellulite
and the subcutaneous tissue
of the buttocks and thighs.
J Drugs Dermatol.
2006;5:714-722.
5. Zelickson B, Kist D,
Bernstein E, et al.
Histological and
ultrastructural evaluation
of the effects of a
radiofrequency-based
nonablative dermal
remodeling device: a pilot
study. Arch Dermatol.
2004;140:204-209.
6. Hsu T, Kaminer M. The use
of nonablative
radiofrequency technology to
tighten the lower face and
neck. Semin Cutan Med Surg.
2003;22:115-123.
7. Kist D, Burns AJ, Sanner
R, Counters J, Zelickson B.
Ultrastructural evaluation
of multiple pass low energy
versus single pass high
energy radio-frequency
treatment. Lasers Surg Med.
2006;38:150-154.
8. Burns AJ, Holden SG.
Monopolar radiofrequency
tissue tightening--how we do
it in our practice. Lasers
Surg Med. 2006;38:575-579.
9. Narins D, Narins R.
Non-surgical radiofrequency
facelift. J Drugs Dermatol.
2003;2:495-500.
10. Narins RS, Tope WD, Pope
K, Ross E. Overtreatment
effects associated with a
radiofrequency
tissue-tightening device:
rare, preventable, and
correctable with subcision
and autologous fat transfer.
Dermatol Surg.
2006;32:115-124.
11. Iyer S, Suthamjariya K,
Fitzpatrick R. Using a
radiofrequency energy device
to treat the lower face: a
treatment paradigm for a
nonsurgical facelift.
Cosmetic Dermatol.
2003;16:37-40.
12. Weiss RA, Weiss MA,
Munavalli G, Beasley KL.
Monopolar radiofrequency
facial tightening: a
retrospective analysis of
efficacy and safety in over
600 treatments. J Drugs
Dermatol. 2006;5:707-712.
13. Finzi E, Spangler A.
Multipass vector (mpave)
technique with nonablative
radiofrequency to treat
facial and neck laxity.
Dermatol Surg. 2005;31(pt
1):916-922.
14. Hardaway CA, Ross EV.
Nonablative laser skin
remodeling. Dermatol Clin.
2002;20:97-111, ix.
15. Ruiz-Esparza J, Gomez J.
The medical face lift: a
noninvasive, nonsurgical
approach to tissue
tightening in facial skin
using nonablative
radiofrequency. Dermatol
Surg. 2003;29:325-332.
16. Fritz M, Counters JT,
Zelickson BD. Radiofrequency
treatment for middle and
lower face laxity. Arch
Facial Plast Surg.
2004;6:370-373.
ADDRESS FOR CORRESPONDENCE
Flor Mayoral MD
7300 SW 62nd Place
PH West
South Miami, FL 33143
phone: 305-665-6166
fax: 305-662-4649
e-mail: flormayoral@aol.com
Flor A. Mayoral MD
Flor A. Mayoral Dermatology
Group, South Miami, FL
Author Flor A.
MayoralCOPYRIGHT 2007
Journal of Drugs in
Dermatology, Inc.& Gale
Group
Laser skin tightening:
non-surgical alternative to
the face lift
The drive for cosmetic
enhancement of facial skin
with minimal risk and rapid
recovery has inspired
nonsurgical means of wrinkle
and photodamage reduction
through laser skin
resurfacing. Since its
inception in the 1980s and
early 1990s, laser skin
resurfacing has evolved from
ablative technologies to
non-ablative and fractional
resurfacing in an effort to
minimize risk and shorten
recovery times. Over the
past several years, a great
deal of emphasis has been
placed on increasing
penetration depth, collagen
shrinkage, and skin
tightening through the use
of radiofrequency and, more
recently, infrared
wavelengths. The compelling
aspect of this approach is
that it is possible to
achieve a degree of skin
tightening, providing a
potential future alternative
to surgical face-lifting.
Radiofrequency devices
generate electrical energy
which heats the dermis at
relatively low temperatures
and without the production
of plume. The first such
energy source was the
monopolar radiofrequency
device, ThermaCool
(Thermage). This
radiofrequency technology
was the first to
specifically target laxity
of the face and neck. (1) A
uniform volumetric heating
effect is delivered into the
dermis as a result of the
tissue's resistance to the
current flow. The electric
field polarity changes 6
million times per second,
and the charged particles
within the electric field
change orientation at that
frequency. The resistance of
the tissue to the particular
movements then generates
heat. The advantages of this
system include the minimal
post-operative erythema
which resolves within hours
and the lack of significant
risk of side effects.
Disadvantages of the
ThemaCool system initially
included the significant
discomfort during treatment
and inconsistency in
results. In a minority of
patients, dramatic
improvement was observed,
but the majority of patients
experienced minimal
improvement. In a study of
the ThermaCool TC system to
treat the lower face of 16
patients, only 5 of 15
patients (one-third)
reported satisfactory
results and photographic
analysis did not yield
statistically significant
results. (2) Recently,
modifications of the
technology and the protocol
have improved the
consistency and extent of
improvement by increasing
the size of the tip and
conducting multiple passes
at lower energy settings.
(3)
The combination of
electrical and optical
energy (elos) was the
subsequent advance to this
area, allowing for
augmentation of the
non-ablative effects
achieved with either
modality alone. The
combination of bipolar
radiofrequency (RF) with
infrared laser at 900 nm and
intense pulsed light
(500-1200 nm) at lower
fluences (Galaxy, Syneron)
has been shown to result in
the systematic reduction of
skin laxity and all aspects
of photodamage and rhytids.
(4-5) This combination
technology has also been
assessed for striae
(Alexiades-Armenkas,
unpublished data, 2006) and
cellulite. (6) It will be
important to compare these
evaluations to the laser or
pulsed light without RF
control, which is necessary
to test the hypothesis
regarding a synergistic
effect of the RF on outcome.
Most recently, a combined
monopolar and bipolar RF
device has been designed
(Accent, Alma Lasers),
theoretically allowing
greater flexibility in
penetration depths
applicable to a greater
variety of anatomic sites.
Currently undergoing trials
for FDA approval for skin
tightening of facial skin
laxity as well as for body
cellulite, it will be
interesting to monitor how
this device compares to
prior modalities in its
level of efficacy. One
important potential
advantage to this system is
the minimal discomfort
associated with treatment,
obviating the need for
topical anesthesia. Early
indications are promising
with respect to efficacy in
the radiofrequency skin
tightening arena, though
published data are still
pending.
Another method of skin
tightening employing a new
infrared device emitting
wavelengths from 1100-1800
nm (Titan, Cutera) has
been introduced for the
treatment of skin laxity.
This technology is also
proposed to induce
volumetric heating of the
dermis, followed by tissue
contraction. Early results,
which await peer-review,
indicate safety and a
moderate degree of efficacy
in treating skin laxity. In
a preliminary study of 25
patients using fluences of
20 to 30 J/[cm.sup.2],
immediate changes and
moderate improvement in
facial rhytides were
reported. (7) In another
preliminary split-face
design study comparing this
modality to RF, less
improvement was observed
with the infrared device.
(8) It will be of import to
monitor the efficacy of this
device as the final reports
become available.
In sum, laser skin
tightening using
radiofrequency or infrared
energy sources is a
compelling area of active
research and currently
provides a less effective
alternative to surgical
face-lifting. As newer,
more effective devices are
rapidly becoming available,
the objective of achieving
the non-surgical face lift
may soon become a reality.
Journal of Drugs in
Dermatology, Macrene
Alexiades-Armenakas MD PhD
References
1. Jacobson LG,
Alexiades-Armenakas MR,
Bernstein L, Geronemus RG.
2003. Treatment of
nasolabial folds and jowls
with a non-invasive
radiofrequency device. Arch
Dermatol.
2003;139(10):1313-20
2. Hsu TS, Kaminer MS. The
use of nonablative
radiofrequency technology to
tighten the lower face and
neck. Semin Cutan Med Surg.
2003;22(2):115-23.
3. Dover JS, Zelickson B,
Atkin D, et al. A
multi-specialty review and
ratification of standardized
treatment guidelines for
optimizing tissue tightening
and contouring with a
non-invasive monopolar
radiofrequency device. Amer
Soc Derm Surg Abstracts.
October 28, 2005.
4. Sadick N,
Alexiades-Armenakas M,
Bitter P, Hruza G,
Mulholland S. Enhanced
full-face skin rejuvenation
using synchronous intense
pulsed optical and
conducted, bipolar
radiofrequency energy
(ELOS): introducing
selective
radiophotothermolysis. J
Drugs Dermatol.
2005;4(2):181-6.
5. Doshi SN, Alster TS.
Combination radiofrequency
and diode laser for
treatment of facial rhytides
and skin laxity. J Cosmet
Laser Ther. 2005;7(1):11-5.
6. Sadick NS, Mullholland
RS. A prospective clinical
study to evaluate the
efficacy and safety of
cellulite treatment using
the combination of optical
and RF energies for
subcutaneous tissue heating.
J Cosmet Laser Ther.
2004;6(4):187-90.
7. Ruiz-Esparza J. New
infrared device can produce
immediate and long-term skin
contraction by painless low
fluence irradiation. Amer
Soc Derm Surg Abst. Atlanta,
GA, October 28, 2005.
8. Lee M-W C. Comparison of
radiofrequency vs. 1100-1800
nm infrared light for skin
laxity. Amer Soc Derm Surg
Abst. Atlanta, GA, October
27, 2005.
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