Radiofrequency: Review of literature

Abstract

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.

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© 2019 Turkish Journal of Plastic Surgery | Published by Wolters Kluwer - Medknow
62
Abstract
Original Article
IntroduCtIon
Skin rejuvenation and fat loss constitute a signicant part
of plastic surgery’s aesthetic operations. While facelifts for
facial rejuvenation, blepharoplasty operations, liposuction,
and contour restoration are performed using plastic surgery
techniques, nonsurgical patients and nonsurgical physicians
and aestheticians focus on noninvasive and minimally invasive
methods. Noninvasive and minimally invasive (in some
societies, so-called medical aesthetics) methods have reached
an ever-growing economic dimension with increasing demand
due to the introduction of various devices and products to the
market. Manufacturers, marketers, users, and practitioners who
want to increase their share in the aesthetic market sometimes
claim that the results are comparable to the surgical operations.
However, it is not possible to obtain a result that is comparable
to surgeries. There are a couple of exceptions; one of them is
Botox practice. It is frequently used for the rejuvenation of the
upper face and, nowadays, has greatly reduced the requirement
of aesthetic surgery operations including the lifting up of
forehead and brow, even though the results are temporary.
However, there is no other minimally invasive or noninvasive
method other than Botox, reaching the satisfactory results as
the surgical outcomes.
Radiofrequency (RF) is an important method among ablative,
noninvasive, and minimally invasive methods used for
rejuvenation, regional fat loss, and contour restoration. Because
it can be applied to all kinds of skin types, RF has been adopted
from the beginning and gained popularity in this eld. With
the widespread use of RF, various RF devices have emerged;
different application techniques are being dened and continue
to be developed.
radIofrequenCy teChnology and deVICeS
Previously, RF was initially used for cauterization purposes.
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 efciency. 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.
Keywords: Laxity, noninvasive, radiofrequency, skin tightening, wrinkle
Address for correspondence: Prof. Metin Görgü,
Deaprtment of Plastic Reconstructive and Aesthetic Surger y,
Abant Izzet Baysal University, Bolu, TR 14280, Turkey.
E‑mail: metingorgu@gmail.com
Access this article online
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DOI:
10.4103/tjps.tjps_65_18
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How to cite this article: Görgü M, Gökkaya A, Kizilkan J, Karanl E, Dogan A.
Radiofrequency: Review of literature. Turk J Plast Surg 2019;27:62-72.
Radiofrequency: Review of Literature
Metin Görgü, Ali Gökkaya, Jehat Kizilkan, Ertugrul Karanfil, Ali Dogan
Department of Plastic Reconstructive Surger y, Abant Izzet Baysal University, Bolu, Turkey
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In 2002, ThermaCool (SoltaMedical, Inc., formerly Thermage,
Hayward, CA, USA) started using a 6-MHz frequency device
for the treatment of skin tightening and facial wrinkles
following the Food and Drug Administration approval.[1-9]
Initially, noninvasive lasers and light sources were used for skin
tightening, wrinkle reduction, and skin rejuvenation. However,
with the ability of RF devices that can be used in all types of
skin, they have reached a common use over time.[1,2,9-11] As it
becomes popular in the market, different RF devices are being
developed with a combination of many techniques. Due to the
high demand for rapid, noninvasive and minimally invasive
skin rejuvenation techniques, nowadays, various devices are
being manufactured and techniques are being introduced.[1,2,9]
RF technology includes any electromagnetic wave frequencies
within the range of 3 KHz to 300 MHz.[7] An RF eld is
composed of both electrical and magnetic components. The
frequency range of RF devices used in skin rejuvenation ranges
from approximately 0.5–40 MHz. The frequency of RF device
is important, and it is inversely proportional to the depth of
penetration. It is known that the lower frequencies have higher
penetration rates.[12] For instance, the penetration depth of 40
MHz frequency will remain supercial compared to that of a
frequency of 1 MHz.
The tissues have a resistance against electrical currents
(impedance) and this resistance creates heat; therefore, the RF
penetration depth is calculated by tissue impedance and RF
frequency. Energy (J) = I2 × R × T (I: Current, R: Impedance,
t: Time/seconds).[1,2,6,7] As can be seen with formula, the heat
that will emerge is directly related to the power of the electrical
current and the tissue resistance. As a result, the same result
in different areas and different individuals with the same RF
current cannot be obtained. Different tissues will have different
resistances, and similar tissues will have different resistances in
different individuals. Therefore, either of the target temperature
should be monitored, or the practitioner must have enough
experience to achieve adequate heating.
The electrical conductivity of each tissue is different.[3] Electrical
conductivity is elevated in regions with high blood circulation.
The bone has a poor electrical conductivity. Thickness of the
dermal layer in patients may also vary at different anatomical
sites (2–5 mm). Likewise, skin properties, such as having
cellulites, require deeper heating of the subcutaneous layers.
Conversely, other conditions, such as rhytids, require reduced
heating of the dermis layer.[12] High-impedance tissues, such
as subcutaneous fat, generate greater heat and account for the
deeper thermal effects of RF devices.[6,13] The heat generated by
the RF will depend on the resistance of the tissue to the electrical
current. Therefore, in different tissues, heat will form at different
degrees and different depths. For this reason, it is more likely
to obtain nonreliable results. Therefore, the procedure must be
done on the same tissue by the same person.
deVICe headS
The RF stream is transmitted to tissue by a header.
Noninvasive heads can be monopolar (with grounding used,
heads without grounding are called unipolar heads), bipolar,
multipolar, and fractional. Minimal invasive headers include
fractional (with microneedle heads insulated or noninsulated)
and subcutaneous probes.
The monopolar head is usually used in conjunction with a
grounding located in the right arm, and in practice, the current
is directed from the monopolar head to the ground that turns the
tissue resistance to heat in order to obtain the deepest effect.
In this way, the depth control can also be estimated. Bipolar,
tripolar, or multipolar heads have + and − poles on the same
head. For this reason, no grounding is required. The current
ows between two poles of the head and the depth at which
the current reaches is assumed to be half of distance between
two electrodes.[12,14] However, it should be noted that the depth
will also vary with different frequencies. When the RF energy
is transferred from the monopolar head as electromagnetic
radiation rather than as a current, the obtained dielectric heating
is rather resistive heating, so no grounding is required, and it
is called unipolar RF.[15]
Fractional minimally invasive RF devices may be divided
as bipolar or multipolar and electrode fractional RF or
microneedle fractional RF.[15] In fractional RF, multiple
electrode arrays (pins) or paired microneedles are used for
heating the tissue. There are some untreated areas left to help
accelerating wound healing and maintaining skin integrity.[9,16]
Different histologic patterns of fractional injury may be
produced by using noninsulated or insulated needles. While
the use of noninsulated needle creates fractionalize damage
to the epidermis, insulated needles only heat an area of the
sphere at the tip of the needle, protecting the epidermis and
the dermoepidermal junction.
In subdermal or subsurface minimally invasive RF devices
(ThermiTight; ThermiAesthetics, Southlake, TX, USA),
subdermal heating temperature is measured using a thermistor
attached to the tip of the subdermal internal probe (55-65 C
for dermis, 70°C for fat), while the surface temperature is
measured using a thermal imager (42°C–45°C) and thus a
controlled heating can be provided.[16,17-19] The subdermal probe
can be placed directly into the RF target tissue invasively to the
desired depth, and the nerves mapped with the nerve stimulator
can be provided with a temporary Botox effect by heating at
85°C for 1 min.[17,18,20]
In RF applications, combining variables (frequency,
current duration, tissue resistance, head type, noninvasive
usage, etc.,) with other technologies have resulted in a broad
variety of different RF devices. Thermage/Thermacool is
the rst RF device for the treatment of wrinkles and has a
frequency of about 6 Mhz. Thermage/Thermacool warms
deep tissues with a monopolar head under computer control.
The Thermage CPT system (Solta Medical, Hayward,
California, USA) is a vibration setting incorporated with a
handpiece of monopolar RF[8] [Figure 1]. The system has a
digitally pulsed cryogen spray unit which enables precooling,
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parallel cooling, and postcooling of the epidermis.[8] The
monopolar RF Trusculpt (Cutera) has its own large electrode
RF current reaching to 7–15-mm deep and providing heat
for fat apoptosis, thus aiming for fat reduction.[20] EndyMed
Intensif applicator (EndyMed Ltd., Caesarea, Israel) uses an
array of 25 noninsulated gold-plated microneedle electrodes
with a maximum penetration depth of 3.5 mm.[21,22] Exilis
system (BTL Aesthetics, Prague, Czech Republic) and
Pelleve (Ellman International, Inc., Oceanside, NY, USA)
use a continuous motion technique to deliver RF energy to
the skin[20] [Figure 2]. Today, there are various devices that the
frequencies can be adjusted. VR52 (VCA laser, Beijing, China)
uses 1–40 MHz adjustable RF energy with monopolar, bipolar,
and tripolar face (small) and body (large) heads [Figure 3].
INFINITM (Lutronic Corp., Goyang, South Korea), is a High
Intensity Focused RF system which has 1 MHz RF, with bipolar
array of insulated microneedles (7x7/1 cm2) that are embodied
in a single-use disposable tip [Figure 4]. Because the shaft of
the needle is insulated, there is no electrothermal damage to
the epidermis and the dermoepidermal junction. Therefore,
epidermal cooling is not needed.[23]
Different heads can be used for a single device and can be
combined with other technologies. Different techniques
such as infrared (IR) light, vacuum, mechanical massage,
cooling, light-emitting diode, and high-intensity focused and
micro-focused ultrasound are being combined with RF to
increase synergistic interaction to improve skin rejuvenation
and tightening effect.[1,2,18,24]
named teChnologIeS and trademarkS (™)
Manufacturers name the technologies and even the applications
heads as TM. For example, Tune Face™ is a cooled,
vacuum-assisted unipolar, 40.68-MHZ, 6-pin, fractional
RF applicator, used for the face.[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. While special names can sometimes emphasize a
signicant technological difference, they sometimes aim to
increase commercial popularity.
In SVC technology, the device controls the RF energy
penetration depth as a shallow, medium, and deep by controlled
sequence of paired electrodes at different distances in a
fractional RF handpiece.[27] The switching process converts
between three RF frequencies, providing supercial moderate
Figure 1: The Thermage system (the photos are from Thermage internet
web. URL: https://www.thermage.com/hcp#the‑thermage‑system)
Figure 2: Pelleve radiofrequency machine and radiofrequency body head:
Photos are from Ellman website (URL: http://ellman.com/index.html,
http://ellman.com/pellefirm‑system.html)
Figure 3: VR52 radiofrequency Machine
Figure 4: 7 × 7 microneedle head of INFINITIM radiofrequency Device:
Photo is from Luthronic website (URL: https://int.aesthetic.lutronic.com/
intl/products/infini/)
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and profound effect.[27] CORE technology is applied by
combining three different frequencies (0.8, 1.7, and 2.45 MHz)
with vacuum and massage [Figure 5]. 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).
[24,26] Polaris(900 nm diode laser combined with bipolar RF,
Syneron Israel) and Aurora (IPL combined with bipolar RF
Syneron Israel),[26,28] now Elos-plus (Syneron-Candela Israel)
are devices with ELOS technology which is combining light
with bipolar RF. The Accent System (Alma Lasers, Ltd.,
Caesarea, Israel) is a RF system that uses two RF congured
handpieces on a single platform: unipolar, which permits
volumetric (deep), and bipolar, which does supercial tissue
heating, it is now known as Accent Prime and has many different
types of heads. [Figure 7].[29] Using RADIO4 (Via dei Guasti
29, 20826 Misinto, Milan, Italy), Nicoletti et al. histologically
demonstrated ex vivo and in vivo samples of epidermal
and dermal results of noninvasive heating with a 1-MHz
four-electrode system with RF.[30] VelaShape III (Syneron
and Candela) combines optical energy with bipolar RF, using
pulsed suction and mechanical massage for deeper penetration
and heating the tissue.[28] eMatrix (Syneron-Candela, Irvine,
CA, USA) is a minimally ablative fractional bipolar RF which
uses an array of paired microneedles to get rejuvenation with
low epidermal disruption and high dermal remodeling.[24,28,31]
Venus Freeze (Venus Concept, Toronto, Canada) is a multipolar
RF, which uses pulsed electromagnetic eld that stimulates
broblast proliferation, angiogenesis, and collagen synthesis
in a nonthermal manner.[28,31] EndyMed PRO™ 3 (Endymed
medical, Caesarea, Israel) (3DEEPR) is a technology, using
a multipolar RF with real-time skin impedance readings,
handpieces for facial and body sites[22,31-33] [Figure 8]. It
is a multisource RF system platform which consists of
nonablative skin tightening, ablative fractional RF, and ablative
microneedles RF[33] [Figure 9]. Pelleve (Ellman International,
Inc., Oceanside, NY, USA) 4-MHz monopolar RF system
Figure 5: Channeling optimized radiofrequency energy technology: The
photos are from Viora website. URL: https://www.vioramed.com/en/
technologies/core‑technology
Figure 6: Electro‑optical synergy technology: The photo is from
Candela‑Syneron Web site (URL: https://syneron‑candela.com/na/
technology/elos‑technology)
Figure 7: Accent prime: The photo is from Alma Lasers Web site (URL:
https://www.almalasers.com/alma‑products/accent‑prime/)
Figure 8: Endymed radiofrequency machine: Photo is from website of
Endymed (URL: http://www.endymed.com/)
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with multiple-size tips provides continuous motion and
surgical electrocautery capability.[24,30] ePrime (Syneron) is a
microneedle bipolar RF.[31] There are also some personal-use
RF devices.[34-36]
Where do We uSe radIofrequenCy
Using RF devices, skin wrinkles and various skin conditions
can be treated, including periorbital rhytids, lower cheek jowl,
nasolabial folds, marionette lines, lower lid tightening, brow
lifting, atrophic scaring, acne and acne scarring, cheek laxity,
neck rejuvenation, and axillary hyperhidrosis.[37] Over time,
RF usage areas are expanding. Fistonić et al. used monopolar
focused noninvasive 3.25-MHz RF device for labia tissue
tightening.[38] Key and Boudreaux and Biesman and Pope used
RF on eyelid rejuvenation (by protecting eye with a plastic
ocular shield).[5,39] Pongsrihadulchai et al. used nanofractional
RF device for striae alba.[40] For posterior upper arm skin laxity,
a subdermal thermistor-controlled monopolar RF was used.[19]
Ideally, the patient group will consist of individuals with
mild, moderate laxity, mild lines, and wrinkles between 35
and 60 years of age. For severe laxity and deep wrinkles,
invasive surgical methods, such as face/neck lifting, should be
considered. Anticipation of the patient is important, and it is
necessary not to apply RF to the patient who can get successful
results only by invasive surgeries.
meChanISm of radIofrequenCy treatment
RF induce tissue tightening and contour changes through
dermal collagen remodeling without disruption of the overlying
epidermis as a noninvasive procedure with a short recovery
period and small risk of adverse effects.[1,2,6,10,11]
RF produces heat deep in the dermis due to tissue electrical
resistance.[1] With RF application, different levels and different
degrees of heat are produced under the skin. The heat increases
collagen denaturation that results in shrinkage and the desired
rejuvenation effect. The RF effect is achieved by heating the
broblasts to such an extent that they stimulate the production
of collagen and allow the collagen and elastic bers to shrink.
As a result, the skin becomes thicker, rmer, and more tense.[12]
In RF applications, the temperature of the same tissue varies
depending on the depth of the tissue, the frequency, the power
of the devices, the types of the head, the maximum temperature
reached, the heat exposure time, and tissue hydration as well
as tissue type and age.
Collagen is composed of triple helix of proteins connected by
interchain hydrogen bonds. When collagen is heated with RF,
the bonds are affected, triple helix degrades, collagen part is
denatured and contracted.[9] The tissue is burnt as a result of
overheating. Ideal shrinkage temperatures range from 57°C
to 61°C,[9] but the time of the heat applied is important as
well. The effect of mechanical stress on broblasts stimulates
extracellular matrix remodeling, which occurs after the
contraction phase of wound healing.[12] It has been shown that
mechanical stretching causes an increase in Type I and Type III
collagen expression,[12] demonstrating that mechanical stress
alone can also act on collagen and skin without heat effects.
Fibrous septa: Heating deeper tissue disrupts brous septa,
and the result is three-dimensional tissue contracture. With
the shrinkage and contracture of the brous septa between
the subdermal fat tissues, there is not only a tightening in the
horizontal plane of the skin but also a shortening in the vertical
plane (Z-dimension).
Capillary blood ow and adipocytes: RF heating increases
local capillary blood flow which increases adipocyte
metabolism. Moreover, nonthermal effects of RF include
adipocyte stimulation, leading to lipase-mediated degradation
of triglycerides or even adipocyte apoptosis.[9] The heating
effect increases microcirculation, homogenizes subdermal
fat, and increases skin elasticity.[12] Thermal exposure at 43°C
for 10 min results in a delayed adipocyte cellular death,[12,20]
and thermal exposure at 45°C for 3 min results in a loss of
cell viability in 60% of adipocytes. In vivo fat cell lipolysis is
enhanced by increased delivery of catecholamine hormones,
which is improved by enhancement of blood ow.[12]
Fibrous septa contract to inward as deeper effect of RF.[9] RF
stimulates neocollagenesis, elastin, and ground substance
production, which results in delayed dermal tightening and
contour changes.[9]
Immediate posttreatment biopsies after RF do not give much
evidence. However, perivascular and perifollicular inltrates
can be seen after a few weeks, and a similar amount of
shortening and shrinkage in collagen bers is shown in electron
microscopic evaluation.
The RF current, like SIRT6, upregulates Sirtuin genes while
downregulating SIRT1, 3, 5, and 7, resulting in new collagen
formation and increased broblast survival.[28]
An electromagnetic field from which the RF current is
generated has thermal and nonthermal effects.[13] For the
thermal effect, almost everyone agrees that there is a collagen
contraction and shrinkage of collagen as well as the stimulation
Figure 9: Radiofrequency mıcroneedle handpıece: Photo is from website
of Endymed (URL: http://www.endymed.com/site/products.php)
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of collagen synthesis.[13] Nonthermal biologic effects occur
in cell membrane receptors and channels, which induce
cytoprotective growth factor synthesis, heat shock genes,
synthesis of mucopolysaccharide and elastic bers (improve
rmness and elasticity of skin), increase enzyme activity,
transcription of specic genes, mRNA expression.[13]
As the skin tensioning and tightening effect takes place at a
depth of about 5 mm, monopolar and low frequencies may be
required when an effect of vertical effect in brous septa and
fatty tissue is desired.
temperature of radIofrequenCy heatIng
RF heats dermis[1-7,10,11,17,41-44] up to a point to obtain therapeutic
effect without damaging the surrounding tissues. It is important
to keep the temperature below 45°C for epidermal (surface) heat
treatment of the skin when aiming 3–6-mm deep dermis heat at
around 65°C in the RF applications.[9] Fibroblasts are thought
to be stimulated for the production of collagen when heated
at 55°C–65°C.[29] Subdermal probe measurements showed
that collagen remodeling at 42°C–46°C, septal tightening at
55°C–65°C, lipolysis, liposculpting at 65°C–70°C, and nerve
damage at 85°C can be obtained.[18] Elman et al. suggested that
skin temperatures must reach 50°C, for skin collagen formation
and cell proliferation. However, for skin tightening and lifting
effects, the dermis should be heated up to 40°C–50°C.[27]
Sufcient heating in the tissues depends on electrical current,
duration, and tissue resistance. Tissue resistance differs
signicantly between the patient and the treatment area.[3]
Lack et al. pointed out that the highest level of impedance
occurs at arms, then the forehead, cheeks, and back.[3]
Although minimally invasive RF devices are considered to
be more effective and controlled in heating dermis without
damaging the surrounding area, aesthetic patients are easier
to adapt to noninvasive methods and their demands toward
this are increasing.
The use of RF emphasizes the importance of heating the dermis
up to 65°C–75°C in the literature, while the temperature of the
epidermis should not exceed 42°C–45°C. It is not possible to
measure the temperature of the dermis noninvasively, although
it is possible to measure the temperature in the epidermis with
IR cameras. Minimally invasive RF devices are important for
this reason. Their aim is to heat the desired point to create a
heat at the exact target point. Minimally invasive devices that
measure temperature in both supercial and subdermal tissues
were developed, and such devices can directly measure the
temperature of the application area with a thermistor located
at the tip of the internal probe, while epidermal temperatures
are measured directly with an IR camera system. This type
of dual system provides temperature-controlled dermal and
subdermal tissue therapeutic thresholds necessary for collagen
remodeling.[16]
Dermis needs to be heated to achieve a clinical effect with RF,
although there are different opinions about how much heat will
be generated in the dermis. 55°C–65°C is considered to be
sufcient for the clinical effect. It is not possible to measure
the heat formed in the dermis, except using an invasive RF with
a subdermal probe during in vivo application for experimental
investigations. Sufcient results cannot be obtained with
suboptimal heat. For this reason, the patient’s response to
exposure to heat, the observation of changes in the skin, and
the experience of the doctor are important.
hIStopathology
RF application results have been evaluated histopathologically
in many in vivo and ex vivo studies. In addition to the immediate
effects achieved by RF, there are fibroblast, adipocyte
stimulation, and increased capillary circulation and delayed
effects. Hence, homogenization of histopathological changes
is difcult and changes occur after hours, days, and weeks
in the tissues following an application. In Belenky’s study,
the subcutaneous tissue sample was discontinued due to a
microtrauma that happened 8 h following RF on pork skin,
and the new connective tissue formation showed that healing
process was visible.[12]
Alvarez et al. showed histopathological changes including
partial detachment of the stratum corneum, follicular dilation,
arrangement of melanin pigment in irregular clusters, irregular
areas of epidermal hyperplasia, congestion and dilation of the
dermal blood vessels, dermal edema, and increased dermal
thickness in series of biopsies after RF application.[45]
Immediate heating results in collagen denaturation with a
resultant brous contraction and tissue thickening determined
by transmission electron microscopy studies.[46]
eValuatIng the reSultS of radIofrequenCy
treatmentS
Clinical observation and patient feedback are more widely used
in assessing RF outcomes, rather than limited histopathological
changes. Pritzker et al.[31] draw attention to the inadequacies
between the techniques used in skin rejuvenation, and
even the comparative evaluation of technologies, as well
as the differences in assessment standards and subjectivity.
Radiologic and ultrasonic measurements of tissue thickness
and histopathological ndings support the effectiveness of RF,
but it is not possible to evaluate the RF results objectively.
Subjective assessments are based on the visual interpretation
of doctors, observers, and participants. Different Classication
Systems such as the Fitzpatrick Wrinkle classication,[1] the
Lael laxity classication system, and the Alexiades laxity
scale[1,4,7] are used in this assessment because the results are
hard to standardize. Measurements are made to the standard
with the help of some devices; the physical measuring
device (BTC-2000, SRLI Technologies, Nashville, TN,
USA) measures both elasticity and skin stiffness.[44] Likewise,
Wakade et al. used ultrabiomicroscopic sonography to measure
decrease in subepidermal low-echogenic band of the nasolabial
folds after RF and glycolic acid peeling treatments.[47]
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hoW to uSe radIofrequenCy
It is aimed to heat the target with RF application, the target
is often dermis and collagen at the region and the treatment
area may also contain brous septa, fat tissue, and nerves in
the subcutaneous tissue. The epidermis needs to be protected
during dermal heating. Keeping the epidermal heating at
39°C–42°C temperature range will be enough to protect the
tissue. How we provide this with the RF device depends on the
different devices and their characteristics. On some devices,
RF is applied to a eld with a single touch, while in some
devices the RF header is circulated at the area. If the device
does not have a thermal meter to monitor the dermal heat, the
effect is determined by the patient’s skin, and the reaction of
the patient against the heat. In practice, it is useful to have a
thermal camera in hand; now, thermal cameras are very small
and can be adapted to tablets and mobile phones.
During application, it may be necessary to change the power
of the RF current, while more current is required in regions
where the skin is thicker, and less current is required in regions
where the current is thinner.
It is possible with gel application to protect the epidermis
during RF application and allow the head of the device to
slide easily in the treatment area. If the device does not have
its own cooling system, using a gel will be sufcient. Cold air
can also be applied for epidermal cooling.
No signicant preparation is required before RF application,
but skin cleansing is necessary. Dirt, oil, and makeup materials
that may affect the passage of electrical current must be
removed. The application process is generally done from top
to bottom (“Free-hand”) sweeping (“paint-brush”) motion,
with horizontal strokes and vertical strokes alternating until
the set time expires.
Because RF is not a light-based treatment, eye protection
is not necessary unless applied directly to the eyelids. It is
recommended to have wet gauze placement between teeth and
lip when working on the lips. When we apply RF to the eyelid,
we need a plastic protector for the device and eyes. When Key
et al. applied RF for 6 min using a 10-mm cap on the eyelids
with ThermiSmooth (Thermi, Irving, Tex.), they used a plastic
eye shield for eye protection.[39]
Skin tightening, edema development, pain, and erythema
during application should be closely followed up to reduce the
risk of complications and obtain. Dover et al. suggested that
for optimal energy selection, patient pain feeling feedback is
a valid method, and treating to a clinical endpoint of visible
tightening with multiple passes at moderate energy settings
provides substantial and consistent results.[44]
Application can be performed in varying numbers depending
on device, treatment area, and frequency and electrical current
used.
High energy with fewer pass or low energy with multiple
passes can be applied.[4,20,44] The low energy with multiple
passes will seem relatively safe, but it will be exhausting and
will require a longer time. It may not be homogeneous to reach
therapeutic degree with heat accumulation. With a high-energy
low pass, it is possible to achieve a shorter treatment time
and more homogenous therapeutic doses with increased risk.
Epidermal cooling and moniterization of epidermal heating
is important when high energy with fewer pass is used. The
duration of the application is important for the patient and the
physician. Patients consider it as a lunch break application and
they want to complete the treatment as soon as possible. As
for physician’s perspective, time is very valuable, therefore
shortening treatment time by using high-dose single-pass
setting will be preferred, but we must remember applying high
energy is risky. RF treatments are popularized with the slogan
of maximal results with minimal side effects,[4,44] Therefore
multipass with lower energy option should be considered
because collagen denaturation with such settings can also be
achieved effectively and safely. In this case, faster and/or wider
treatment headings will be required.
afterCare
Patients do not experience downtime unless there is a
complication after RF application. The patient immediately
feels heat in the skin after treatment, a feeling that lasts for
1–2 h, and almost every patient may have a few hours of
erythema and edema. After the process is completed, the use
of cooling gel, ice pads, and cold air might help. Sometimes,
corticosteroid creams (only once just after RF for erythema)
can be supplemented with sunscreens. It is recommended to
use skin moisturizing creams afterward.
paIn and aneStheSIa
The heating that occurs during RF applications will naturally
be sensed by individuals. As the temperature rises, a feeling
of pain develops. Pain threshold varies signicantly from
patient to patient, and some patients barely tolerate pain. Pain
is described as a brief burning sensation that rapidly dissipates.
The difference between the impedance of individuals shows
different pain complaint during the same energy and frequency
treatments. Therefore, pain sensation is an important indicator
and determines the boundary between the effect and the burn
for the practitioner. For this reason, some practitioners do not
use topical creams that reduce pain. Reducing the sensation
of pain will lead to higher levels of heat, but it is important to
remember that the outcome and the complication limit are close
to each other, and that we do not alter the pain treatment area.
The erythema that occurs during the application will help the
temperature of the skin surface to be measured by a thermal
imager or simply with an IR/laser thermometer to achieve a
degree of protection and therapeutic temperature.
RF application can often be done only by cooling, but
sometimes topical anaesthetic creams or block local anesthesia
or sedation may be used. Inltrative anesthesia is not preferred,
as edema may affect the depth of treatment. Kushikata et al.
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Turkish Journal of Plastic Surgery ¦ Volume 27 ¦ Issue 2 ¦ April-June 2019 69
showed that topical anesthesia did not reduce the pain in RF
application sufciently, so that it could not be applied at higher
energy levels with topical anaesthetic use, but topical anesthesia
did not change RF activity at 3 months of follow-up.[42]
proteCtIon of SkIn
The devices measure the heat of the skin surface and can have
receivers to determine if the target temperature has reached.
However, the heat on the surface may not be correlated with
the heat at the deeper tissue. As the frequency of the RF
device decreases, the depth of heat increases. It is possible to
externally control the surface temperature using coupling uid,
gel, cold air, or peltier.
SeSSIonS
RF application can be done in one session or in many sessions.
The number of sessions and time may vary depending on
the device and protocols implemented by the clinicians.
Multiple-use protocols vary from 4 to 8 sessions and intervals
vary from 1 week to 1 month.[4,10,11,23,29,45,48] Therefore, at rst,
users apply the device with the protocol recommended in the
manual, but modify these protocols depending on the results
they have received over time. As can be seen in the literature,
we can say that there is no standard by looking at the diversity
of protocols, because of the differences in the characteristics
of the devices, racial differences (directly related to RF skin
resistance), and the level of education of practitioners.
ComplICatIonS and ContraIndICatIonS
Among minor complications in the early period include
abrasion, edema, erythema, blistering, blanching, bruising,
crusting, oozing, and purpura, and they emerged as
early clinical manifestations, rather than complications.
They are often handled without causing problems. We
may place scabbing and ulcers among some more serious early
complications; other serious complications include atrophy,
hyperpigmentation, scarring, textural change, white area,
tenderness, and Poison Ivy).[1]
In some cases RF treatment is absolutely or relatively
contraindicated, and in some cases it is not recommended.[8,12]
At the same time, we need to pay attention to the case of
anatomical structures.
Contraindications of RF; pregnancy, electronic implants
(pacemaker, heart pill e.g.,) cardiac insufciency, active or
recent malignancy, on metal-containing apparatus such as hip
prosthesis, fracture xation, a history of recurrent herpes simplex
(needs preventive antiviral therapy), immune suppression,
active local or systemic infections, dermatologic and vascular
disorders, increased photosensitivity, collagen-vascular
disease, heat-excitable disease, hypertrophic scars, coagulation
disorders, wound healing disorders.
Relative contraindications of RF; diabetes, oral retinoid use
within the last 6 months, topical retinoid use in the last 2 weeks,
topical steroid use within the last 2 months, oral steroid use
within the last 12 months, RF therapy within the last year,
atrophic states of the skin (e.g., chronic radiation dermatitis),
patients unrealistic expectations, chronic corticosteroids or
chronic nonsteroidal anti-inammatory medication usage,
obese patients, patients with uctuating weight, excessive
skin laxity and excess, poor skin quality (severe photodamage,
severe elastosis), poor general or mental health, therapy with
dermabrasion, chemical peeling or laser skin resurfacing within
the last year, therapy with microdermabrasion within the last
3 months, fat augmentation within the last 18 months, over
tattoo or synthetic llers (silicone).
It is safe to use it in patients who have previously undergone
facelift, blepharoplasty, laser surgery Botox, or llers. RF
treatment does not cause facial hair loss; therefore, male
patients can be treated with no fear to beard or mustache loss.
England noted that there was no signicant negative interaction
between RF and various soft-tissue llers (collagen, hyaluronic
acid, calcium hydroxylapatite, polylactic acid, and injectable
liquid) and RF in a ller study using an animal model.[41]
Alam et al. reported that there was no signicant negative
interaction between soft-tissue llers (hyaluronic acid and
calcium hydroxylapatite) and RF in a short term.[43]
dISCuSSIon
Along with improvements in technology, the diversity of RF
devices is increasing, and new devices are introduced having
additional features. Our aim in RF applications is that the
patient and the doctor nd the results satisfactory without any
harm to the patient. This end result will expand the market
share with extra features (such as ease of use, quick application,
short operation time, the ability to use different frequencies and
headings simultaneously, instantaneous temperature changes,
and combined technologies).
The technological advancement is necessary to improve our
knowledge and experience, but encountering new devices
do not mean that we will give up using effective devices
that currently we have. Noninvasive applications in RF
remain important. The main purpose of using noninvasive
RF devices is to heat the dermis and fat tissue noninvasively.
For effective use of the devices and technology, a physician
should evaluate the outcome and the risk interactions, and he
should understand the device, the skin and their relationship.
While RF devices seem easy to use, it is necessary to heat
the skin sufcient enough without creating epidermal burns,
as the experience of the physician increases, it can be used
at the high end limit of the device to make the procedure as
effective as possible. Inexperienced users will have to choose
a more controlled device. The development of the device will
ensure that this heating is done specically at the desired level
without damaging the epidermis. Such devices will remove
the learning curve and increase safety. Noninvasive methods
cannot provide the same results as of invasive or minimally
invasive methods. However, they are preferred by patients as
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Turkish Journal of Plastic Surgery ¦ Volume 27 ¦ Issue 2 ¦ April-June 2019
70
noninvasive, lunch time procedures, with no downtime and
less complications.
Araújo et al. claimed that, in Brazil, in many RF devices, the
power is xed and that it is not possible to obtain the results
of international devices that use power at varying degrees.[13]
It is not easy to standardize studies related to RF. The variables
are too much and it is difcult to control. The number of
new assertive devices are increasing, but in practice the end
point of devices and treatment results are determined by
doctors and patients during application. It is considered that
in the studies done, RF applications are effective for varying
degrees in patient evaluations, such as face-to-face repetitions,
independent evaluation by photographers, Fitzpatrick wrinkle
scale, measurement of changes in forehead height, and biopsies
taken[13] when subjective evaluation standards are used. The
use of inadequate devices or presence of inexperienced,
uninformed practitioners leads to doubt for this method, which
is considered to be effective in practice. Because the frequency
of the end device, the power, and the tissue of the patient will
affect the impedance, it is necessary for the doctor to know
and analyze them to nd the appropriate option. It will be
determined by the experience of the user how many sessions
will be continued or only single session will be used.
The RF should allow the dermis to heat up to around 65°C,
while the skin should remain at 40°C–42°C. However, how
many minutes should the dermis remain at 65°C. Is it enough
to go out of 65°C for only 1 s? For collagen denaturation, both
the heat level and exposure time are important. It is shown that
10% of the collagen bers shrink after heating at 65°C for 10
minutes and 60% shrinkage can be obtained after heating at
80°C for 1.5 minutes.[8]
When using microneedle (insulated or noninsulated) in
minimally invasive RF applications, we clearly know at
what level we apply the RF current to the skin. In this
minimally invasive method, the recovery is faster because
of the fractional-based procedure, and when applied as a
microneedle, the skin also has a dermaroller-like effect.
The insulated needles create fractional heat damage in the
dermis (usually 300 μ deep) only when needle puncture
trauma occurs without any heat effect on the epidermis and
epidermodermal compartment. While using noninsulated
needles, heat injury also forms in the epidermis and
epidermodermal compartments. Controlled damage caused
by the application of the insulated needle can be simulated
by the damage generated by high-focus ultrasonic (HIFU).
Compared to light-based systems, RF applications have the
advantage of being more deeply affected, especially when
there is less risk of hyperpigmentation. However, regeneration
with fractional ablative laser epidermis provides effects such
as correction of texture. Gold et al. using EndyMed Intensive
applicator (EndyMed, Caessarea, Israel) (an array of 25
noninsulated gold-plated microneedle electrodes) found that
3 months of follow-up is more improvement than 1 month
of follow-up in Fitzpatrick’s wrinkle and elastosis scale[21]
and hypothesized that noninsulated RF needles (emit RF
through the whole length of the needle) are more effective
than insulated needles (emit RF only through the tip of the
needle).[21]
We do not have a single device and system to ensure that
everything is perfectly implemented, easy-to-apply, and to
obtain very impressive results without any complications. We
are also faced with many devices that offer different uses of
the same system. It is not easy to make the right choice in this
complexity since it is not always possible to obtain sufcient
and effective results with a single device. Therefore, expensive
investments are inevitable for those working in the aesthetic
sector. In plastic surgery eld, this is a little more difcult, as
the surgeon knows that he/she can get much better results with
operations, and it is not easy to believe that the result will be
achieved with this trait or to be satised with about 20%. For
this reason, the use of dermatology seems to be more prevalent
in the use and operation of such devices.
Devices used in skin rejuvenation alone are not adequate
to solve the problem, for example, HIFU and RF cannot
rejuvenate epidermis, while light-based devices cannot be
used with the same efciency in each skin type. The use of
technologies together sometimes increases the efciency and
sometimes can also bring risks together.
RF devices are constantly and rapidly changing, and it is
difcult for manufacturers to nd the same device 2–3 years
later. In literature reviews, we will not nd a published device
on a website of a consumer rm frequently, but we will
encounter devices with more advanced and different names.
ConCluSIon
RF devices heat the tissues at different depths depending on
their properties. To obtain the effect, the heat to be generated
must be at levels that provide collagen denaturation. The user’s
knowledge and the level of experience are as important as
the device to be used to achieve satisfactory results. The user
should be familiar with the characteristics of the device and
know the properties of the human tissue and the RF physics.
Thermal cameras and IR/laser thermometers will also help.
It is possible to achieve an effective result with RF, but patient
and physician expectations should be realistic. RF applications
are safe if attention is paid to contraindications and the
limits are not exceeded in practice. The complications that
occur are minor and transient. It is safer and more effective
to apply using low-energy multipass instead of high energy
in practice.
It is not possible to achieve a result with RF that is comparable
to the surgical operations.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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