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Combination Radiofrequency and Light Energies: Electro‐optical Synergy Technology in Esthetic Medicine

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In the past decade, there has been an astonishing insurgence in the number and variety of commercially available nonablative resurfacing devices. This is related in part to a continually increasing market demand for noninvasive cosmetic procedures that are associated with minimal recovery time and fewer complications than the traditional carbon dioxide (CO2) laser. The goal of nonablative devices is to selectively heat the target tissues without injuring surrounding tissue. This article reviews the mechanism, results of clinical studies, and treatment parameters for a combination optical and radiofrequency (RF) energies system. To see modest clinical improvement, the patient often requires a series of treatments over the course of several months (sometimes up to 18 months). Preliminary studies with combination optical and RF energies have shown promising results in different dermatologic applications, including skin rejuvenation, hair removal, and leg vein treatment. A new technology that integrates bipolar RF and optical energies, ELOS (Syneron Medical Ltd, Yokneam, Israel), is based on the premise of a synergistic activity between the two forms of energy. The bipolar RF component enables the use of lower levels of the optical component, reducing the risk from optical energy and potentially improving its use across different skin types and hair colors. The optical component is believed to drive the bipolar RF energy to concentrate where the optical energy has selectively heated the target.
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Combination Radiofrequency and Light Energies:
Electro-optical Synergy Technology in Esthetic Medicine
N
EIL S. SADICK, MD, FACP, FAACS
Department of Dermatology, Weill Medical College of Cornell University, New York, New York
BACKGROUND. In the past decade, there has been an astonishing
insurgence in the number and variety of commercially available
nonablative resurfacing devices. This is related in part to a con-
tinually increasing market demand for noninvasive cosmetic pro-
cedures that are associated with minimal recovery time and fewer
complications than the traditional carbon dioxide (CO
2
) laser.
OBJECTIVE. The goal of nonablative devices is to selectively heat
the target tissues without injuring surrounding tissue. This arti-
cle reviews the mechanism, results of clinical studies, and treat-
ment parameters for a combination optical and radiofrequency
(RF) energies system.
METHODS AND MATERIALS
. To see modest clinical improvement,
the patient often requires a series of treatments over the course
of several months (sometimes up to 18 months).
RESULTS
.Preliminary studies with combination optical and RF
energies have shown promising results in different dermatologic
applications, including skin rejuvenation, hair removal, and leg
vein treatment.
CONCLUSION.A new technology that integrates bipolar RF and
optical energies, ELOS (Syneron Medical Ltd, Yokneam, Israel),
is based on the premise of a synergistic activity between the two
forms of energy. The bipolar RF component enables the use of
lower levels of the optical component, reducing the risk from
optical energy and potentially improving its use across different
skin types and hair colors. The optical component is believed to
drive the bipolar RF energy to concentrate where the optical
energy has selectively heated the target.
© 2005 by the American Society for Dermatologic Surgery, Inc. • Published by BC Decker Inc
ISSN: 1076–0512 • Dermatol Surg 2005;31:1211–1217.
DR. SADICK HAS RECEIVED RESEARCH FUNDING AS WELL AS EQUIPMENT AND STOCK OPTIONS FROM
SYNERON.
IN THE past decade, there has been an astonishing resur-
gence in the number and variety of commercially available
nonablative resurfacing devices. This is related in part to a
continually increasing market demand for noninvasive
cosmetic procedures that are associated with minimal
recovery time and fewer complications than the traditional
carbon dioxide (CO
2
) laser. The goal of nonablative
devices is to selectively heat the target tissues without
injuring surrounding tissue. A new generation of intense
pulsed light (IPL) and other nonablative infrared lasers has
improved safety and recovery profiles.
1–9
However, they
are primarily effective in reversing photodamage and treat-
ing fine lines and superficial defects (ie, “dermal remodel-
ing”) and have limited efficacy in treating deeper wrin-
kles.
10,11
To see modest clinical improvement, the patient
often requires a series of treatments over the course of sev-
eral months (sometimes up to 18 months).
12
Radiofrequency (RF) technologies, which use electrical
current rather than light energy, have been introduced as
a new approach for nonablative resurfacing. Instead of
fluence, RF technologies are dependent on the local resist-
ance and local current density to create selective thermal
injury in targeted tissues. The first introduced nonablative
RF device, ThermaCool (Thermage, Hayward, CA, USA),
is reported to deliver uniform and sustained volumetric
heating to the deep dermis and subcutaneous layers
(5–6 mm) at considerably greater depths than that
reported with light-based technologies.
11,13
It has been
used for tissue tightening and treatment of acne.
13–18
Pain
has been a limiting factor, and low incidences of blistering,
burns, and inflammatory nodules have been reported.
The following article reviews a new technology that
integrates electrical bipolar RF and optical energies,
referred to as electro-optical synergy (ELOS; Syneron
Medical Ltd, Yokneam, Israel), for esthetic applications.
The rationale behind ELOS is as follows: (1) a synergistic
effect occurs between the two forms of energy when the
various optical and bipolar RF parameters are set opti-
mally and (2) lower levels of both energies can be used,
potentially reducing the risk of side effects associated with
either optical or RF treatment alone. ELOS-based devices
include Aurora SR for skin rejuvenation, Aurora DS and
Polaris DS for hair removal, Polaris WR for wrinkle reduc-
tion, and Polaris LV for vascular lesions and leg vein
removal. A summary of clinical trials evaluating this sys-
tem is provided in Table 1 and reviewed in the following
section.
Address correspondence and reprint requests to: Neil S. Sadick, MD,
FACP, FAACS, 772 Park Avenue, New York, NY 10021, or e-mail:
nssderm@sadickdermatology.com.
Mechanism and Specifications of ELOS Systems
The mechanism of synergy between the two energies of
ELOS acts in the following manner: The light-based com-
ponent delivers optical energy that is absorbed by specific
chromophores in the skin (ie, melanin, hemoglobin),
which is converted to heat, according to the principle of
selective photothermolysis.
19
The bipolar RF component
produces a thermal effect that is dependent on the electri-
cal conductivity of the tissue. It generates heat from a cur-
rent of ions that acts according to the physical principle of
impedance, that is, electrical current will always follow
the path of least resistance.
20,21
For example, blood has
very high electrical conductivity; therefore, it has low
impedance. Bone has very low electrical conductivity or
high impedance. Electrical current will always follow the
path of highest conductivity (lower impedance); therefore,
it does not penetrate the bone but rather flows around it.
Impedance also is directly, but inversely, correlated with
heat. Higher temperatures produce a lower impedance and
therefore direct the flow of current.
In the combined-energy ELOS system, preheating with
the light component will lower the impedance of the tar-
get tissue and direct the electrical bipolar RF energy to
concentrate at the target site, adding to the selective ther-
mal heating. Therefore, lower optical and bipolar RF ener-
gies can be used to achieve target heating versus either
energy source alone.
22
In addition, precooling of the skin
will increase the impedance of the skin and direct electri-
cal current to a greater depth of penetration. It also helps
protect the epidermis and provides comfort to the patient.
Based on the mechanisms described above, the optimal
treatment method of ELOS is a near-simultaneous appli-
cation of the optical and bipolar RF energies with a pre-
cooling of the epidermis. The steps are summarized as fol-
lows:
1. Hydrate and cool the epidermis.
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Dermatol Surg 31:9 Part 2:September 2005
Table 1. Summary of Clinical Studies with ELOS Systems in Esthetic Medicine
System/Treatment
Study Application/Study Group Settings Results/Findings
Bitter and Mulholland
23
Skin rejuvenation Aurora SR Improvement in erythema and
N = 100 Optical: 28–34 J/cm
2
telangiectasias (70%) and lentigines
Skin types II–IV RF: 20 J/cm
3
and other hyperpigmentations (78%)
Average wrinkle reduction 60%
Doshi and Alster
24
Rhytids and skin laxity Polaris WR Significant improvement in facial and
N = 20 Optical: 15–50 J/cm
2
neck rhytids and modest
Skin types I–VI RF: 40–100 J/cm
3
improvement in skin laxity in the
majority of patients
Del Giglio
28
Hair removal Aurora DS At 3 mo, hair clearance ranged from
N = 60 Optical: 10–28 J/cm
2
64–84%
Skin types II–V RF: 10–20 J/cm
3
Most effective in axillary region
Sadick and Shaoul
29
Hair removal Aurora DS 80–85% hair clearance for black and
N = 40 Optical: 15–30 J/cm
2
brown hair
Skin types II–V RF: 10–20 J/cm
3
40–60% hair clearance for blond, red, or
Different hair colors white hair
3–5 treatments
Sadick and Laughlin
30
Hair removal Aurora DS 44–52% hair clearance for blond or
36 women Optical: 15–30 J/cm
2
white hair
Skin types I–V RF: 10–20 J/cm
3
Blond or white facial hair
2–5 treatments
Laughlin
32
Hair removal Aurora DS 50% of subjects obtained hair clearance
N = 10 Optical: 16–20 J/cm
2
for > 35%
Skin types V–VI type V, 14–17 J/cm
2
for No adverse reactions
type VI
RF: 18 J/cm
3
for type V,
20 J/cm
3
for type VI
Chess
35
Leg vein treatment Polaris LV 77% of treatment sites with 75–100%
25 women Optical: 80–140 J/cm
2
vessel clearance; 13% with 50–74%
Skin types I–IV RF: 80–100 J/cm
3
vessel clearance; 10% with 25–49%
35 treatment sites, with vessel clearance
vessel diameters 0.3–5.0 mm
RF = radiofrequency.
2. Apply optical energy to selectively heat the target
and bipolar RF energy to provide additional ther-
mal energy to the heated target. The applied
energy should be at the level at which the temper-
ature of the epidermis does not exceed the target
temperature.
3. Discontinue optical pulse and continue RF pulse
for additional selective heating of the target.
The ELOS system consists of a bipolar RF generator (90
38 38 cm) and a flashlamp pulsed light delivered
through a contact sapphire light guide with the bipolar RF
energy delivered through electrodes embedded in the sys-
tem applicator and brought into contact with the skin sur-
face. The Aurora uses pulsed light (580–980 nm) for opti-
cal energy, whereas the Polaris uses a high-power diode
laser (900 nm) as its light source. Differences in specifica-
tions between the Aurora and Polaris systems are shown in
Table 2.
The RF component of ELOS systems is a bipolar con-
figuration for both systems. The two electrodes are later-
ally affixed on opposing sides of the rectangular sapphire
light guide. Electrical current is passed between two elec-
trodes and is limited by the area between the electrodes.
The penetration depth of electrical current can be calcu-
lated as half of the distance between electrodes. For exam-
ple, if the distance between electrodes is 8.0 mm, the pen-
etration depth is approximately 4.0 mm. Pulses of optical
and RF energies are initiated at approximately the same
time; however, in the Aurora, the bipolar RF pulse is set at
a longer duration than the optical pulse, enabling the opti-
cal component to preheat the target and increase RF selec-
tivity. The device also includes an active dermal monitor-
ing system that measures changes in the skin impedance,
which is adjustable by the user to provide an integrated
safety mechanism (impedance safety limit) to prevent over-
heating of the dermis. A thermoelectric cooling handpiece
provides contact cooling at a temperature of approxi-
mately 5C before, during, and after energy delivery.
Skin Rejuvenation
Skin rejuvenation refers to treatment of a variety of skin
targets, including pigmented and vascular lesions, wrin-
kles, and overall skin texture.
12
Pigmented lesions, such as
lentigines and café au lait, contain a high concentration of
melanin and are usually superficial. The ideal optical
parameters for treating such lesions are 580 to 1,000 nm,
with a short pulse duration. In contrast, vascular lesions
are more difficult to treat because of the range of vessel
sizes and depths. Wrinkles can be fine and superficial or
deep and more severe. The premise of combining optical
and RF energies for skin rejuvenation and wrinkle reduc-
tion is as follows: The optical energy is primarily respon-
sible for addressing the more superficial aspects of
unwanted pigmentation or dyschromia and visible vascu-
larity, whereas the RF energy is primarily responsible for
heating of the deeper tissue to induce neocollagen forma-
tion.
Bitter and Mulholland recently reported the efficacy
and safety of the Aurora SR, which combines RF and IPL,
for skin rejuvenation.
23
They treated the face and upper
neck of 100 subjects with Fitzpatrick skin types II to IV.
Most subjects had combined clinical indications that
included pigmented and vascular lesions, skin laxity, or
enlarged pores. Each treatment consisted of one to three
passes over the face, using a fluence of 28 to 34 J/cm
2
and
RF current of 20 J/cm
3
. The number of treatments varied
from two to five, depending on lesion type. To determine
the treatment effect, subjects were followed up after their
last treatment and were interviewed about their satisfac-
tion level.
Improvements were observed in erythema and telang-
iectasias (70%) and lentigines and other hyperpigmenta-
tion (78%), as determined by subject satisfaction levels. In
addition, both physicians and patients observed signifi-
cant improvements in fine and coarse perioral, periocular,
and forehead wrinkles, with an average wrinkle reduction
of 60%. The authors noted that wrinkle reduction with
Dermatol Surg 31:9 Part 2:September 2005 SADICK: ELECTRO-OPTICAL SYNERGY TECHNOLOGY IN ESTHETIC MEDICINE
1213
Table 2. ELOS Technologies: System Specifications
Parameter Aurora Polaris
Clinical applications SR – skin rejuvenation WR – wrinkle reduction
DS – hair removal DS – hair removal
LV – leg vein/vascular lesion treatment
RF energy, J/cm
3
5–25 Up to 100
Laser type IPL 900 nm diode laser
580–980 nm (skin rejuvenation)
680–980 nm (hair removal)
Light fluence, J/cm
2
10–45 WR – up to 50
LV – up to 140
Cooling on skin surface 5–20C5C
Treated area, mm 12 25 8 12
Pulse repetition rate, pps 0.7 Up to 2
IPL = intense pulsed light; RF = radiofrequency.
combined optical and RF energies was significantly greater
than that obtained with IPL alone (based on clinical expe-
rience). Moreover, subjects who had undergone both types
of treatments reported a preference for the combined opti-
cal and RF procedure because of a greater degree of skin
improvement, more rapid onset of effects, and slightly
greater treatment comfort. The authors indicated that
complications were transient and treatable and can be
minimized with the proper technique. Superficial crusts
and burns were observed.
Doshi and Alster recently reported the results of com-
bined diode laser and RF energies for rhytids and skin lax-
ity.
24
Twenty patients (skin phenotypes I–VI) with mild to
moderate facial and/or neck rhytids were enrolled. After
application of a topical anesthetic cream, three passes of
the device were delivered to the face and/or neck. The RF
energy ranged from 40 to 100 J/cm
3
; the optical energy
ranged from 15 to 50 J/cm
2
. Patients participated in a
maximum of three treatment sessions at 3-week time inter-
vals. Clinical improvement was graded by both the patient
and the investigator, as well as use of photographs assessed
by two independent assessors blinded to the treatment
protocol. Preliminary results showed significant improve-
ment in facial and neck rhytids and modest improvement
in skin laxity in the majority of patients. Side effects
included transient erythema and edema. The authors con-
cluded that the combination treatment can effectively heat
collagen to achieve immediate skin tightening and delayed
collagen remodeling, thereby resulting in improvement of
rhytids and skin laxity.
Hair Removal
Based on the principle of selective photothermolysis, laser
devices have been effectively used for hair removal because
they target melanin within the hair shaft, hair follicle
epithelium, and heavily pigmented matrix, where the tar-
get chromophore is mostly heavily concentrated.
25–27
How-
ever, the treatment of darker skin phenotypes has been
particularly problematic because of the absorption of opti-
cal energy by melanin chromophores in the epidermis. Of
even greater difficulty, light-colored hair, which contains
low levels of melanin, fails to absorb enough optical
energy to achieve thermal destruction of the hair follicle.
For these reasons, the combined use of optical and bipolar
RF energy is advantageous because the RF component is
not dependent on melanin chromophores to selectively
heat the target and is not absorbed by melanin chro-
mophores in the epidermis. A lower level of optical energy
can be used, making it safer for dark skin phenotypes.
Likewise, light hair may be effectively removed because
melanin chromophore is not the primary target but rather
nonselective RF heating and destruction of the germinative
part of the hair follicle.
In a recent multicenter study, 60 patients with Fitz-
patrick skin types II to V and various hair colors were
enrolled for treatment with the ELOS system.
28
In the
study, optical energy ranged from 15 to 28 J/cm
2
, and the
RF energy ranged from 10 to 20 J/cm
3
. All subjects
received three treatments 6 to 8 weeks apart. Hair counts
were performed prior to the first treatment and 3 months
after the last treatment. Maximum hair reduction was
observed at 2 to 8 weeks. At 3 months, hair clearance
ranged from 64 to 84%, depending on the anatomic site.
Treatment was most effective for hair in the axillary. In
most cases, higher RF energy (15–20 J/cm
3
) was used, and
the results indicate that efficacy is determined by the level
of RF energy, not optical energy.
I conducted two studies to investigate the efficacy and
safety of combined optical and RF energies for hair
removal. The first study consisted of 40 adult subjects with
different skin types (Fitzpatrick skin types II–V) and vari-
ous hair colors.
29
The second study included 36 adult
women with overall lighter skin phenotypes (I–V) and
blond or white facial hair.
30
In both studies, subjects
received four treatments at 8- to 12-week intervals over a
period of 9 to 12 months. Depending on skin and hair
phenotypes, light energy ranged from 15 to 30 J/cm
2
.
Higher optical energy was used in lighter skin phenotypes
and hair color. The RF current ranged from 10 to 20 J/cm
3
,
depending on the anatomic site; higher RF energy was
used in facial regions (versus lower body regions). The
results were monitored 18 months after the first treatment
or 6 months after the last treatment.
In both studies, maximum hair reduction occurred 6 to
8 weeks following treatment, and hair density was
observed to decrease progressively following each subse-
quent treatment. As observed in the first study, hair
removal efficiency was greater in subjects with dark hair
(mean clearance 80–85%). This is similar to that reported
using other light-based technologies.
31
Both studies
showed that light hair phenotypes had hair clearances up
to 60%. The results showed no significant dependence of
treatment on skin color; both light and dark skin types
responded similarly to treatment. Side effects were mini-
mal and transient. In the first study, 20% of subjects had
mild erythema that resolved within 24 hours post-
treatment. In the second study, 8% of subjects had tran-
sient hyperpigmentation that did not require therapy and
14% had mild erythema, which resolved within 24 hours.
Laughlin conducted a study in 10 patients with dark
skin.
32
The group consisted of seven East Indian patients
with Fitzpatrick skin type V and three African American
patients with Fitzpatrick skin type VI. RF energy was set
at 18 and 20 J/cm
3
for skin types V and VI, respectively.
Serial photography and clinical examination were used to
evaluate the subjects at 1 to 3 days, 2 weeks, 1 month, and
4 to 7 months to determine hair loss and adverse effects.
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Dermatol Surg 31:9 Part 2:September 2005
Hair counting was carried out over the entire treatment
area by two blinded, independent observers. The results
showed that 50% of subjects obtained a hair loss of more
than 35%; the mean hair loss for the entire group was
30.2% (range 13–75.4%). None of the patients developed
blistering at the treatment site within 72 hours after treat-
ment. Blistering can occur in darker skin types following
treatment with pure optical energy.
33,34
Leg Vein Treatment
Chess conducted a study to investigate the use of com-
bined optical and RF energies for the treatment of telang-
iectasias, venulectasias, and reticular leg veins.
35
Twenty-
five female patients with Fitzpatrick skin types I to IV and
various sizes and depths of leg veins were enrolled in the
study. Thirty-five sites with vessel diameters varying from
0.3 to 5.0 mm were treated. Energy settings were set
depending on skin type and were increased until a vessel
reaction was observed. The initial optical energy used in
this study ranged from 80 to 120 J/cm
2
. Higher energy lev-
els were used in lighter skin types. The RF setting ranged
from 80 to 100 J/cm
3
. Patients were treated with up to
three treatment sessions at 4- to 10-week intervals. At 1
month and 6 months after the final treatment, approxi-
mately 77% of treatment sites exhibited 75 to 100% ves-
sel clearance, 13% had 50 to 74% vessel clearance, and
10% had 25 to 49% vessel clearance.
Discomfort at the target area was common during
treatment. The average discomfort rating reported was 7
(based on a scale of 1 to 10, with 10 being the worst). One
treatment site developed dysesthesia, which resolved with-
out treatment after 8 weeks. Three sites developed eschars
without any permanent sequelae. Although temporary
ecchymotic or hyperpigmented side effects were common,
there were no permanent dyschromic or textural changes
in any patients.
In this study, total energy up to 140 J/cm
2
of laser
energy and 100 J/cm
3
of conducted RF energy and pulses
in the range of 100 to 300 milliseconds resulted in sub-
stantial clearance of both small and large vessels
(0.3–5.0 mm in diameter).
Conclusions
A new technology that integrates bipolar RF and optical
energies, ELOS, is based on the premise of synergistic
activity between the two forms of energy. The bipolar RF
component enables the use of lower levels of the optical
component, reducing the risk from optical energy and
potentially improving its use across different skin types
and hair colors. The optical component is believed to drive
the bipolar RF energy to concentrate where the optical
energy has selectively heated the target. Recommendations
for bipolar RF and optical treatment settings for the avail-
able ELOS-based systems are provided in Table 3. These
settings do not necessarily reflect those used in clinical
studies but rather are based on clinical experience. Pre-
liminary studies with combination optical and RF energies
have shown promising results in different dermatologic
applications, including skin rejuvenation, hair removal,
and leg vein treatment. Adverse effects include transient
blistering and erythema, which can be minimized with the
proper technique. Further studies to optimize treatment
parameters and technique are under way. Comparative
studies are needed to determine whether the ELOS system,
given its unique combination system, is indeed more effec-
tive and safer than either light or RF sources used alone.
Dermatol Surg 31:9 Part 2:September 2005 SADICK: ELECTRO-OPTICAL SYNERGY TECHNOLOGY IN ESTHETIC MEDICINE
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Table 3. Recommendations for Radiofrequency and Optical Treatment Settings for ELOS Systems (Based on Clinical
Experience)
ELOS System Application Radiofrequency Optical
Aurora SR Skin rejuvenation Use maximum 25 J/cm
3
, except where 18–45 J/cm
2
depending on skin type
contact is compromised
(only available to skin type IV)
Aurora DS Hair removal Use maximum 25 J/cm
3
12–30 J/cm
2
depending on skin type and
response
Polaris WR Wrinkle reduction 50–100 J/cm
3
30–50 J/cm
2
Polaris DS Hair removal 35–50 J/cm
3
14–30 J/cm
2
depending on skin type and
response
Polaris LV Vascular lesions, leg 70–100 J/cm
3
70–110 J/cm
2
vein removal
Use lower levels in areas with thin skin, such as the jawline and forehead.
References
1. Goldberg DJ, Rogachefsky AS, Silapunt S. Non-ablative laser treat-
ment of facial rhytides: a comparison of 1450-nm diode laser treat-
ment with dynamic cooling as opposed to treatment with dynamic
cooling alone. Lasers Surg Med 2002;30:79–81.
2. Goldberg DJ, Samady JA. Intense pulsed light and Nd:YAG laser
non-ablative treatment of facial rhytids. Lasers Surg Med
2001;28:141–4.
3. Goldberg DJ, Cutler KB. Nonablative treatment of rhytids with
intense pulsed light. Lasers Surg Med 2000;26:196–200.
4. Hardaway CA, Ross EV, Paithankar DY. Non-ablative cutaneous
remodeling with a 1.45 microm mid-infrared diode laser: phase II. J
Cosmet Laser Ther 2002;4:9–14.
5. Hardaway CA, Ross EV, Barnette DJ, Paithankar DY. Non-ablative
cutaneous remodeling with a 1.45 micron mid-infrared diode laser:
phase I. J Cosmet Laser Ther 2002;4:3–8.
6. Tanzi EL, Williams CM, Alster TS. Treatment of facial rhytides with
a nonablative 1450 nm diode laser: a controlled clinical and histo-
logic study. Dermatol Surg 2003;29:124–8.
7. Trelles MA, Allones I, Velez M. Non-ablative facial skin photoreju-
venation with an intense pulsed light system and adjunctive epider-
mal care. Lasers Med Sci 2003;18:104–11.
8. Trelles MA, Allones I, Luna R. Facial rejuvenation with a nonabla-
tive 1320 nm Nd:YAG laser: a preliminary clinical and histologic
evaluation. Dermatol Surg 2001;27:111–6.
9. Woo WK, Handley JM. A pilot study on the treatment of facial
rhytids using nonablative 585-nm pulsed dye and 532-nm Nd:YAG
lasers. Dermatol Surg 2003;29:1192–5.
10. Alster TS, Lupton JR. Are all infrared lasers equally effective in skin
rejuvenation. Semin Cutan Med Surg 2002;21:274–9.
11. Nelson JS, Majaron B, Kelly KM. What is nonablative photorejuve-
nation of human skin? Semin Cutan Med Surg 2002;21:238–50.
12. Sadick NS. Update on non-ablative light therapy for rejuvenation: a
review. Lasers Surg Med 2003;32:120–8.
13. Iyer S, Suthamjariya K, Fitzpatrick RE. Using a radiofrequency
energy device to treat the lower face: a treatment paradigm for a non-
surgical facelift. Cosmet Dermatol 2003;16:37–40.
14. Fitzpatrick R, Geronemus R, Goldberg D, et al. Multicenter study of
noninvasive radiofrequency for periorbital tissue tightening. Lasers
Surg Med 2003;33:232–42.
15. Hsu TS, Kaminer MS. The use of nonablative radiofrequency tech-
nology to tighten the lower face and neck. Semin Cutan Med Surg
2003;22:115–23.
16. Narins DJ, Narins RS. Non-surgical radiofrequency facelift. J Drugs
Dermatol 2003;2:495–500.
17. Ruiz-Esparza J, Gomez JB. The medical face lift: a noninvasive, non-
surgical approach to tissue tightening in facial skin using nonablative
radiofrequency. Dermatol Surg 2003;29:325–32.
18. Ruiz-Esparza J, Gomez JB. Nonablative radiofrequency for active
acne vulgaris: the use of deep dermal heat in the treatment of mod-
erate to severe active acne vulgaris (thermotherapy): a report of 22
patients. Dermatol Surg 2003;29:333–9.
19. Anderson RR, Parish JA. Selective photothermolysis: precise micro-
surgery by selective absorption of pulsed radiation. Science
1983;220:524–7.
20. Duck FA. Physical properties of tissue. New York: Academic Press;
1990.
21. Gabriel S, Lau RW, Gabriel C. The dielectric properties of biological
tissues: III. Parametric models for the dielectric spectrum of tissues.
Phys Med Biol 1996;41:2271–93.
22. Sadick NS, Makino Y. Selective electro-thermolysis in aesthetic med-
icine. Lasers Surg Med 2004;34:91–7.
23. Bitter P Jr, Mulholland S. Report of a new technique for enhanced
non-invasive skin rejuvenation using a dual mode pulsed light and
radio-frequency energy source: selective radiothermolysis. J Cosmet
Dermatol 2002;1:142–3.
24. Doshi SN, Alster TS. Combined diode laser and radiofrequency
energy for rhytides and skin laxity: investigation of a novel device.
Cosmet Laser Ther 2005;7:11–5.
25. Lask G, Elman M, Slatkine M, et al. Laser-assisted hair removal by
selective photothermolysis. Dermatol Surg 1997;23:737–9.
26. Nanni CA, Alster TS. A practical review of laser-assisted hair
removal using the Q-switched Nd:YAG, long-pulsed ruby, and long-
pulsed alexandrite lasers. Dermatol Surg 1998;24:1399–405.
27. Ross EV, Laden Z, Kreindel M, et al. Theoretical considerations in
laser hair removal. Dermatol Clin 1999;17:333–55.
28. Del Giglio A. Hair removal using a combination of electrical and
optical energies: 3-month clinical study [data on file]. Yokneam
(Israel): Syneron Medical Ltd; 2002.
29. Sadick NS, Shaoul J. Hair removal using a combination of conducted
RF and optical energies: an 18-month follow-up. J Cosmet Laser
Ther 2004;6:21–6.
30. Sadick NS, Laughlin SA. Effective epilation of white and blond hair
using a combined radiofrequency and optical energy. J Cosmet Laser
Ther 2004;6:27–31.
31. Ort RJ, Dierickx C. Laser hair removal. Semin Cutan Med Surg
2002;21:129–44.
32. Laughlin SA. Epilation in dark skin (types V and VI) with integrated
radio-frequency and optical energy [data on file]. Yokneam (Israel):
Syneron Medical Ltd.
33. Alster TS, Bryan H, William CM. Long-pulsed Nd:YAG laser-
assisted hair removal in pigmented skin. Arch Dermatol
2001;137:885–9.
34. Nanni CA, Alster TS. Laser-assisted hair removal: side effects of Q-
switched Nd:YAG, long-pulsed ruby, and alexandrite lasers. J Am
Acad Dermatol 1999;41:165–71.
35. Chess C. Prospective study on combination diode laser and bipolar
radiofrequency energies (ELOS) for the treatment of leg veins. J Cos-
met Laser Ther 2004;6:86–90.
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SADICK: ELECTRO-OPTICAL SYNERGY TECHNOLOGY IN ESTHETIC MEDICINE
Dermatol Surg 31:9 Part 2:September 2005
... Elōs technology, which combines optical energies (laser or light) with bipolar RF energy, has been proven in previous clinical studies to be a safe and effective treatment modality for the cosmetic improvement of aging and photo-aged skin, while keeping unwanted side effects and downtime to a minimum [10,11]. By adding RF energy to light (IPL) energy, the light energy level can be lowered while compensating for this lower light energy by RF energy. ...
... IPL has been shown in previous studies to be useful in the treatment of solar lentigines and general skin rejuvenation with improvement of the cosmesis of the aging skin [6,7,23]; however, the broadband light source works largely superficially and, therefore, is less effective for wrinkles, lines and skin tightening. RF energy, on the other hand, has been shown to be very effective in the treatment of wrinkles and lines and other aspects of the aging skin [2, 4,5,10,11,17,[24][25][26]. In this study, we compared the efficacy, safety, and tolerability of a combined RF and IPL treatment to IPL energy only treatment in the aging hands of 13 healthy Caucasian female patients aged 47 to 75 years (mean age 64 years) with Fitzpatrick Skin Type III. ...
Article
Full-text available
Different treatment modalities are used for the treatment and esthetic improvement of aging hands. This study evaluated the efficacy and safety of a novel technology, which combines bipolar radio frequency (RF) and optical energies for the cosmetic treatment of aging hands. The objective of the study was to assess the efficacy, safety, tolerability, and patient satisfaction of combined bipolar radiofrequency and optical energies vs. optical energy alone for the treatment of aging hands. Thirteen female patients with solar lentigines on the back of the hands were enrolled. Participants received three treatments: combined RF and intense pulsed light (IPL) on one hand and IPL treatment alone on the other. Standardized clinical photographs were taken, and patient and investigator improvement assessment (Global Esthetic Improvement (GAI) scale), patient satisfaction, and tolerability were evaluated. At the 1 and 3 months follow-up, skin laxity and pigmentation, investigator and patient improvement assessments, and satisfaction were significantly better in the hand treated with combined bipolar RF and IPL. This study demonstrates the safety and efficacy of combining RF and optical energies for the esthetic improvement of aging hands. Combined RF and IPL treatment was more efficient than IPL alone in improving skin pigmentation, skin laxity, and texture.
... [15] Similar to the heads, also, some devices are found on the market in the market with popular names that summarize the method. Examples include channeling optimized RF energy (CORE); [12] electrooptical synergy (ELOS); [6,25] switching, vacuum, and cooling (SVC); and functional aspiration controlled electrothermal stimulation (FACES). [26] The practitioner should examine these types of technologies and know what they mean. ...
... In Viora (Reaction™; Viora Inc., Jersey City, NJ, USA), SVC is combined with CORE technology. [12] ELOS combines light devices such as bipolar RF and diode laser and IPL [25] [ Figure 6]. FACES use negative pressure to suction skin into a bipolar RF head, and gel or liquid applied on the skin to protect the epidermis (Aluma-System, Lumenis Inc., Santa Clara, California, USA). ...
Article
Full-text available
Background: Radiofrequency (RF) devices have widespread use in skin rejuvenation. Although they are used noninvasively, recently minimally invasive RF devices are being added to the inventory to increase their efficiency. Because RF devices do not operate on a light basis, their effects are independent of skin color and type. Therefore, they have a broader spectrum of patients compared to other noninvasive and minimally invasive devices. Skin rejuvenation with RF devices will continue to be important for plastic surgeons to pursue the nonsurgical operations. With RF application, heat is generated at different levels and different degrees under the skin. Methods: Shrinkage and denaturation of the collagen with temperature increase the likelihood of desired rejuvenation effects. The degree of temperature increase in RF applications depends on the frequency of the devices, the power of the devices used, and the characteristics of the headers. Today, different types of RF devices are offered by manufacturers. Heating with an RF device in a therapeutic dose of the skin is possible if appropriate frequency and adequate power are provided. When the therapeutic temperature is close to the complication limit, the user needs to know the device well, be aware of the skin structure at the application site and skin thickness, as well as can adjust the application doses well to get better therapeutic results. Conclusion: The wide variety of RF devices has led to the development of different application methods for users. In this article, RF devices, mechanisms of action, methods of use, clinical practice techniques, and results are reviewed. Even though the results are good, RF applications are not an alternative to a surgery.
... It has been postulated the application of two forms of energy may be synergistic [100]. With this in mind, Taub et al. [101] designed one trial with 21 patients with moderate-tosevere rosacea: participants were treated with a system that combined pulsed light and radiofrequency. ...
Article
Full-text available
Unlike other rosacea therapies which need daily takings or applications over long periods, the edge of lasers and light-based therapies (LLBT) is the limited number of sessions to achieve improvement. The proper selection of the adequate physical device in accordance with the patients’ skin features and rosacea-related signs and symptoms should be considered and the management with physical sources should be updated as new data become available. This article reviews and discusses the current use of lasers and light-based therapies in rosacea with reference to all the available literature. This systematic review demonstrates the quality of evidence to support any recommendation on LLBT in rosacea is low-to-moderate. Among all the available devices, PDL holds the most robust evidence. Treatments options should be tailored for each specific clinical scenario as it is unlike that single modality results in complete resolution. Platforms that include two or more devices and combined therapies with topical agents are suitable and they warrant further investigations.
... 20 Integration of optical and electrical bipolar RF energies, referred to as electro-optical synergy, allows for a synergistic effect to occur between the 2 types of energy and lower levels of both energies to be used, potentially decreasing the risk of complications associated with either RF or optical treatment alone. 21 Several studies have demonstrated hypertrophic scars clinical improvements after light and energy-based therapies. 2,15,[22][23][24][25] However, comparative studies of the various devices are lacking. ...
... 20 Integration of optical and electrical bipolar RF energies, referred to as electro-optical synergy, allows for a synergistic effect to occur between the 2 types of energy and lower levels of both energies to be used, potentially decreasing the risk of complications associated with either RF or optical treatment alone. 21 Several studies have demonstrated hypertrophic scars clinical improvements after light and energy-based therapies. 2,15,[22][23][24][25] However, comparative studies of the various devices are lacking. ...
Article
Full-text available
Introduction: Hypertrophic scars are fibroproliferative disorders, seen after burn, trauma, and/or surgery. We aimed to compare the clinical and histopathological results of 1064-nm Nd:YAG laser and combined intense pulsed light and radiofrequency in the treatment of hypertrophic scars. Methods: Fifty patients with hypertrophic scars were included in this prospective, randomized study. Twenty-five patients were treated with Nd:YAG laser and 25 patients with combined intense pulsed light and radiofrequency (E-light). The scars were evaluated at baseline, during and at 3 months after the final treatment session using the Vancouver scar scale. Biopsy specimens from scars were obtained before, during, and 3 months after the final treatment session and were stained with hematoxylin and eosin stain, Masson's trichrome stain, and immunostaining procedures for collagen I, collagen III, and TGF-β1. Results: Significant improvements in the total Vancouver scar scale scores before and after the treatment in both groups (P < 0.001); however, a significant difference between both groups (P < 0.001), regarding the E-light, which showed better response than Nd:YAG laser. Hematoxylin and eosin and Masson's trichrome staining showed arrangement and thinning of collagen bundles and reduction in collagen density by in both groups, but the collagen bundles thinning and parallelism were more obvious in the E-light group. Significant decrease in the concentration of collagen I, collagen III, and TGF-β1 in the E-light group as compared with the laser group (P = 0.005, P = 0.003 and P < 0.001, respectively). Conclusions: Both modalities were successful in the treatment of hypertrophic scars; however, a significant improvement in the clinical and histopathological findings was detected with the E-light method.
... Bai, Gálvez et al. 2017),,(Hannemann, Mommers et al. 2014),(Lee, Lisanby et al. 2016),(Sadick 2005),(Sartorius, Demirakca et al. 2016),(Shah, Wadoo et al. 2013), 2017a), (EU 2017b), (FDA 2016), (ICNIRP 1998), (ICNIRP 2009), (ICNIRP 2010), (ICNIRP 2017), (IEEE 2002),(Kromhout, Slottje et al. 2017),(Missling, Riel et al. 2016),(Russ and Kessler 2016),(SHEER 2018),(Sozialministerium 2017), (SSK 2017), der Literatur erwähnte Evidenz zu Nebenwirkungen von Verfahren der elektrischen, magnetischen, hochfrequenten, Plasma-und Schallstimulation haben wir in Abbildung 26 zusammengefasst. Wir verwenden dafür die in 7.1 erläuterten Evidenzkategorien. ...
Technical Report
Full-text available
Das Vorhaben wurde mit Mitteln des Bundesministeriums für Umwelt, Naturschutz und nukleare Sicherheit (BMU) und im Auftrag des Bundesamtes für Strahlenschutz (BfS) durchgeführt.
... [1][2][3][4][5][6] Moreover, in order to achieve synergistic skin rejuvenation effects while exploiting minimum energy output, several new-generation devices couple radiofrequency energy with laser/light sources, pulsed-electromagnetic fields, and suction modules. [7][8][9][10][11][12][13] Another breakthrough in the field of radiofrequency devices is the introduction of fractional radiofrequency that delivers energy through an array of microscopic columns of spatially confined thermal injury ...
Article
Background: The latest generation of radiofrequency, nanofractional radiofrequency, allows the heat energy to be delivered through the use of pins or needles as electrodes, facilitating increased efficacy and reduced pain, downtime, and side effects. Objective: The objective of this prospective pilot clinical study was to evaluate the efficacy of nanofractional radiofrequency in skin resurfacing. Methods and materials: Seventeen subjects were enrolled in the study, and each received three nanofractional radiofrequency (160-pin tip) treatments in the facial area at 3-week intervals. Follow-up visits were scheduled at 1 and 2 months after the final treatment. Clinical photography, patient, and investigator assessments were conducted during the treatment visits and follow-up. Results: All subjects completed the study. At the 1- and 2-month follow-up, there was a moderate to significant improvement (2.6 and 3.5, respectively, P = .01) according to the investigator global esthetic improvement scale rating. Most subjects reported that they were satisfied or very satisfied with the outcome and level of comfort. Conclusion: Nanofractional radiofrequency is a safe and effective strategy for improving texture, tone, and skin laxity with high patient satisfaction and tolerable safety profile.
Article
Edematous fibrosclerotic panniculopathy, better known as cellulite, is a skin condition that affects 80%–98% of postpubertal women. Cellulite is believed to be a result of the effects of estrogen on the dermal and subcutaneous fat, including but not limited to fibroblast proliferation, lipogenesis, adipocyte hypertrophy, and collagen formation. These findings are most commonly located in the buttocks, thighs, and abdomen. Not surprisingly, many women seek out treatment to minimize the appearance of cellulite. With a growing understanding of cellulite, there has also been substantial growth in the treatment options available to target the problem. Topical agents, energy‐based devices, injectable treatments, and surgical treatments have all been used to treat cellulite, with significant studies performed to ensure the safety and efficacy of each. In this article, we will discuss these available treatments for cellulite.
Article
Background: Photoepilation has become a very popular epilation procedure in esthetic and cosmetic practice. There are some types of lasers and other light sources used for epilation. Aims: The purpose of our study was to compare a IPL device with an IPL plus RF in one device, using a within-patient, right-left controlled study design. Patients/Methods: Thirty-three patients completed four treatment sessions and the follow-up period of the study. Results: Hair reduction was effective after the first treatment, but similar results were achieved using the IPL system alone, and with IPL combined with RF. The degree of hair reduction increased after the following treatments, but the two methods yielded similar effects. 3 months after the last treatment, some hair had regrown in both treatments, the combined IPL with RF treatment gave significantly better results than the IPL treatment alone. Conclusions: In conclusion, IPL and IPL-RF are effective hair reduction therapies, yielding similar effects in patients with skin phototypes II or III. However, IPL-RF can be more effective in long-term observations. These therapies are also safe and regarded be quite comfortable in this population.
Chapter
IntroductionEssential ConceptsPearls and ProblemsConclusions
Article
Background and Objectives: Non-ablative technologies are playing an increasing role in the management of photoaging. Newer radiofrequency technologies have added to this therapeutic armamentarium. Shorter wavelength technologies are more effective in targeting pilosebaceous vascular and pigmentary alterations while longer wavelength technologies are most effective in wrinkle reduction mediated through dermal remodeling. An overiew of the various technologies available to the practicing laser surgeon are outlined in the present review. Lasers Surg.Med.32:120-128,2003. (C) 2003Wiley-Liss, Inc.
Chapter
This chapter discusses the electrical and dielectric properties of tissue, covering the frequency range from d.c. to over 10 GHz. The electrical character of tissues over a wide range of frequencies may be described by using the two properties relative permittivity, ∈′ (the charge) and conductivity, σ (current densities set up in response to an applied electric field of unit amplitude). From both of these, the complex relative permittivity, ∈*, can be defined by the equation where ∈″ is the dielectric loss. Also, relative permittivity is the term used for dielectric constant for a quantity that may vary greatly. For tissues of multiple relaxations, the Cole–Cole equation needs to be used. The dielectric properties may also be expressed in terms of the complex conductivity, σ*, and can further be written as an equation equivalent to the Cole–Cole equation. At frequencies up to the radio-frequency range, relatively simple bridge techniques provide accuracy within a few percent for both ∈′ and σ. For measurements up to microwave frequencies, coaxial line reflection methods may be used. Factors affecting dielectric properties are noted to be as follows: frequency, temperature, changes following death, animal species, water content, and local tissue variability. In piezoelectric materials, electric charge is generated as a result of an applied stress; the material will alter its dimensions under the effect of an applied electric field. The piezoelectric coefficients, dij, characterize the effect in terms of the charge generated for unit applied stress under short circuit conditions.
Chapter
This chapter discusses thermal conduction through tissue and its heat capacity. A variety of methods may be used to measure the thermal properties of tissue samples; the techniques used may be categorized as invasive or noninvasive, and in each case, it may enable steady-state or non-steady-state measurements to be made. Also, a set of semi-invasive techniques has been investigated in which temperatures have been measured using cutaneous and subcutaneous thermocouples with surface heat fluxes provided by various non-invasive sources. On the other hand, totally noncontact methods use external radiation to heat tissue and observe the subsequent time-course of skin temperature with a radiometer. The thermal conductivity, k, of tissues at temperatures above freezing may increase while showing a very slight positive temperature coefficient. It is generally recognized that tissues may be considered more accurately for thermal analysis as being composed of water, protein, and fat. Subsequently, thermal conductivity may then be expressed as , and ωn are thermal conductivity, density, and mass fraction of the nth component respectively and ρ the density of the composite material. While for temperatures below freezing, the specific heat of tissues, C, varies markedly with temperature in a manner depending strongly on the tissue water content. For the calculation of thermal capacities, the following equation may be used: where ωn is the mass fraction of the nth component and Cn its specific heat.
Article
With current nonablative laser modalities for rejuvenation, a modest reduction in facial rhytides and texture often requires multiple treatment sessions. The radiofrequency (RF) energy device is a new technology that seems to induce tissue tightening after only a few treatment sessions. In this article, we describe use of an RF energy device, the ThermaCool TC™ System (Thermage, Hayward, Calif), in treating the lower face; present a simple treatment protocol; and suggest that RF energy technology shows promise in tightening tissue in the lower face and anterior neck and has few potential complications when performed with the proper technique.
Article
Background. Rejuvenation of photoaged skin involves removal of the epidermis and superficial dermis, encouraging the production of new epidermis with collagenesis and remodeling. The facial appearance during healing is unpleasant, and the complication rate is high. Objective. We evaluate a Q-switched Nd:YAG laser operating at 1320 nm, with a cryogen delivery system and a skin temperature sensor. The system cools the target skin, followed by the laser impulse which passes through the cooled epidermis into the dermis. Methods. Ten patients are presented. Two treatments a week were given over 4 weeks, and the patients were seen at 2 and 6 weeks after the final treatment. Results. The histology showed improvement in the condition of the dermis in all 10 patients, but only 2 of the 10 patients expressed satisfaction with the results, despite similar histologic findings. Conclusions. Careful patient selection is required. Better patient education is necessary to ensure that the patients' expectations are realistic. We should add treatments that will improve the youthful aspect of the epidermis. The system may well help in maintaining the effects of collagen remodeling following traditional ablative resurfacing procedures, but studies are necessary to show this.
Article
Background and Objective The aim of this study was to evaluate the efficacy and complication rate of a nonablative nonlaser light source in the treatment of rhytids. Laser resurfacing, in the treatment of facial rhytids, has involved ablative methods, with their associated complications and limitations. Rhytid improvement requires dermal collagen remodeling. Interest has begun to focus on the use of wavelengths that preserve the epidermis but deliver enough energy to promote rhytid improvement.Study Design/Materials and Methods Thirty subjects with class I–II rhytids and Fitzpatrick skin types I–II were treated with up to four treatments with an intense pulsed light source. Subjects were evaluated 6 months after the final treatment.ResultsTwenty-five subjects showed some improvement in the quality of skin. No subjects were found to have total resolution of rhytids.Conclusion Nonlaser intense pulsed light may effectively improve some facial rhytids. Such improvement can occur without epidermal ablation. Lasers Surg. Med. 26:196–200, 2000. © 2000 Wiley-Liss, Inc.