Ebook Lasers in dermatological practice Part 2

Chapter

8

Nonsurgical Tightening
Simal Soin, Kabir Sardana

Introduction
Numerous attempts have been made at counteracting the signs of aging, such
as redundant facial and neck skin. In terms of skin laxity specifically, the gold
standard of treatment remains rhytidectomy or surgical redraping. However,
with the recent advances in technology, conditions that once required major
surgical intervention may not always require aggressive intervention. Though
nonablative lasers (long pulse 1,064 nm Nd:YAG), and fractional lasers
have been used, radiofrequency (RF), infrared, and ultrasound devices are
probably better, though the last is yet to find universal acceptance (Table 8.1).
Radiofrequency energy works to tighten and lift tissue by delivering heat
to dermal structures without adversely affecting the epidermis, thus making
it an ideal choice for the nonsurgical face-lift. This energy is produced by an
electric current that does not diminish by tissue scattering or absorption by
a chromophore. Light-based treatments such as lasers and infrared devices
rely on chromophores to produce antiaging effects.
Ultrasound waves induce molecules in deep tissue to vibrate, resulting
in tissue heating. Like RF energy, the ultrasound waves spare the epidermis
Table 8.1 Overview of devices for skin tightening
Device

Skin tightening mechanism

ThermaCool TC

Monopolar RF

Accent

Bipolar RF and unipolar RF

Refirme ST

IR and bipolar RF

Polaris WR

Monopolar RF and diode
laser (910 nm)

Titan

IR

Lux-IR

Fractional IR

GentleYAG

Long-pulse Nd:YAG

USG

Ulthera

Nonsurgical Tightening  295

and cause selective heating of the deeper tissues. We will focus on minimally
invasive, nonablative tissue tightening techniques, including radiofrequency,
light and ultrasound-based devices. These devices are not a replacement for
surgical procedures and appropriate patient selection remains key to overall
satisfaction.

Radiofrequency
Therapeutic use of RF technology was first introduced by Bovie and Gushing
in the 1920s with the advent of electrocautery. Since then, it has been used for
a variety of medical purposes. The discovery that this energy could penetrate
deep into the dermis and fibrous septae that support underlying structures
via the emission of high-frequency radio waves suggested that this technology
could also be used to lift and tighten aging skin.
Apart from the three major subtypes, monopolar, bipolar and unipolar RF,
some devices that are labeled to be tripolar or multipolar but are variations of
the basic three forms of monopolar, bipolar, or unipolar (Table 8.2).

Combination Devices
Recently, devices combining RF and light systems were introduced in an
attempt to treat both skin laxity and rhytides. These include the ReFirme ST
and the Polaris WR systems. ReFirme ST combines broadband IR (700–2,000
nm) and bipolar RF energies (70–120 J/cm3), while the Polaris WR TM system
(Syneron Medical Ltd, Israel) combines RF and 900 nm diode laser energies,
known as electro-optical synergy or ELOSTM. The optical energy component
is used to selectively heat the target tissue. Other energy sources, such as
laser or intense pulsed light, can be combined with RF so that a large array of

technologies use RF for the ultimate goal of smoothing and tightening of the
skin (Table 8.2).

Principles of RF
It accomplishes its tissue tightening effects via a unique scheme that utilizes
MRF energy at a wavelength of 6 MHz. The energy is applied to the skin
via a handpiece that contains a single-use electrode tip. A thin capacitive
membrane located on the electrode couples RF to the skin by distributing
RF energy (in the form of an electrical current) over a volume of tissue under
the surface membrane. A return electrode is placed at a distant site on the
body, usually on the back, and an electromagnetic field is created that rapidly
alternates from positive to negative charge. As charged molecules pass
through the electrical field, heat is generated by the resistance of dermal and
subcutaneous tissues to the passage of the electric energy (Fig. 8.1A).


296  Lasers in Dermatological Practice
Table 8.2 Comprehensive classification of RF devices*
Company and
device

Energy specifications

Tips/
electrodes

Comments

Biorad
GSD Tech Co,

Shenzhen,
China

1.15 MHz
1,000 W

3 tips

Continuous cooling; automatic
resistance technology; single and
continuous mode

Cutera
TruSculpt,
Brisbane, CA

1 MHz

4” handpiece

Handpiece reads out once
optimal temperature is reached
of
43–45° C

Ellman
Pelleve,
Oceanside, NY

4 MHz

4 small handpieces
7.5, 10, 15, 20
mm

Several handpieces for smaller
areas. Can use unit as an
electrocautery unit also
RF + Cautery

Thermage
Solta Medical,
Hayward, CA

6.78 MHz
400 W

New handpiece (CPT:
Comfortable Pulse Technology)
with vibrations to improve
patient comfort. Pain nerval
interceptors get confused
and busy (vibrations, cooling,
heating)

Accent Family
Alma Lasers,
Caesarea, Israel

40.68 MHz

Up to 300 W

Unipolar+ bipolar+ fractionated
RF

Aluma
Lumenis Ltd.,
Yokneam, Israel

40.68 MHZ Up to
300 W

Bipolar and
Unilarge
handpieces

Apollo-TriPollar
Pollogen,
Tel Aviv, Israel

1 MHz 50 W

3 handpieces

Aurora SR
Syneron/
Candela,
San Jose, CA

Up to 25 J/cm2

400–980 nm
580–980 nm
680–980 nm

Elos Plus
Syneron/
Candela,
San Jose, CA

1–3 HZ
Variable

eMatrix
Syneron/
Candela,
San Jose, CA

Up to 62 mJ/pin

Monopolar
Devices

Bipolar RF

FACES technology using
functional aspiration

RF + IPL

RF + Infrared light

Matrix of
electrodes
Fractional RF

Disposable tip, which can prove
to be a disadvantage over
conventional fractional lasers

Contd...


Nonsurgical Tightening  297
Contd...
Company and
Device

Energy
specifications

Tips/electrodes

Comments

EndyMEd PRO 3
Deep 3 Pole
EndyMEd
Medical,
Caesarea, Israel

1 MHZ 65 W

4 handpieces

3 Deep RF, Handpieces: Skin
tightening, body contouring,
facial tightening, fractional skin
resurfacing

Eprime Syneron/
Candela,
San Jose, CA

460 kHZ
84 VRMS

Microneedles

20 degree delivery angle,
injected into dermis, fractional
skin resurfacing

eTwo
Syneron/Candela,
San Jose, CA

62 mJ sublative;
100 J/cm3
sublime

Matrix of
electrodes

RF + IR

Ray Life
Ascepelion

0.5-1 mHz

3 handpieces

Suction and three modes

Reaction
Viora,
Jersey City, NJ

0.8, 1.7, 2.45
MHz
Body 50 W
Face 20 W

4 modes- 0.8, 1.7,
2.45 and
multichannel

SVC (suction, vacuum, cooling)
devices

TiteFx
Invasix, Yokneam,
Israel

1 MHz 60 W

VelaShape II
Syneron/Candela,
San Jose, CA

Infrared- Up to
35 W RF
Up to 60 W

Velasmooth
Syneron/Candela

700–2,000 nm

Venus Concept-8
Circular Poles
Venus Freeze,
Toronto, ON

RF: 1 MHz
Magnetic
pulse: 15 Hz
RF: up to 150-W
Magnetic flux:

15 Gauss

V-Touch
Viora, Jersey City,
NJ

Bipolar w/suction real time
epidermal temperature monitor
Handpiece with
bipolar
Radiofrequency,
Infrared laser,
Suction

Vsmooth (40 mm × 40 mm) and
Vcontour (30 mm × 30 mm)
treatment areas

RF/Infrared light with
mechanical manipulation
Large hand­
piece 8
poles 5 mm
apart,
dual mode =
bipolar
magnetic field

Multipolar RF and magnetic
pulse

3 hand
piece-0.8,1.7,
2.45

SVC (suction, vacuum, cooling)
devices

1 handpiece

Unipolar energy to heat fat,
bipolar to deliver energy to
dermis

Non Contact

Operator independent

Unipolar RF
Accent RF
Alma Lasers,
Caesarea, Israel

40.68 MHz Up to
200 W

Multipolar
Devices
Vanquish
BTL Aesthetics,

Prague, CR

*Please contact manufacturers for procedural details


298  Lasers in Dermatological Practice

The device’s energy output is calculated using the following formula:
Energy (J) = I2 × z × t
where I is current, z is impedance, and t is time in seconds. Energy (J) is
created by the impedance ( z ) to electron movement relative to the amount
of current ( I ) applied and the total time ( t ) that current is delivered to the
tissue. The heat generated is in the temperature range of 65–75°C, which can
cause collagen damage, induction of an inflammatory response, thereby
resulting in skin lifting and tightening (Fig. 8.1B).

Mode of Action
Monopolar RF (Thermage) causes immediate skin tightening through
collagen contraction since it heats the collagen in the dermis and fibrous
septae in the subcutaneous fat layer. The body interprets the heat as a wound
and results in wound healing over a period of time. The wound healing
response results in clinical skin tightening. Patients have improvement in

Fig. 8.1A: A diagrammatic overview of the mode of delivery of RF in ‘Thermage’. The
electrical current passes through a single electrode in the handpiece to a grounding
pad. There is a high density of power close to the electrode’s surface with the potential
for deep penetration of tissue heating

Fig. 8.1B: Illustration of the mechanism of collagen remodeling due to RF

Nonsurgical Tightening  299

superficial laxity through collagen tightening in the dermis and subcutaneous
laxity through tightening of the fibrous septae in the subcutaneous layer. To
denature collagen requires heating the tissue to a therapeutic temperature
and then keeping it at that temperature.
The thermal effect causes the collagen to denaturize and this is transposed
into a breaking of the intramolecular bonds. Thus, the molecular structure of
collagen is therefore shorter and thicker, which translates into a “tensor effect”
that is visible and palpable (skin tightening). The thermal shock produces on
the fibroblasts an increase in the production of physiological collagen.
It should be emphasized that this very heat can produce problems if too
much heat is delivered as the collagen fibrils will denature completely above
a critical heat threshold. Conversely, if too little heat is delivered, there will be
no tissue response, although it appears that mild thermal injury gives rise to
new dermal ground substance and tissue remodeling of photodamaged skin
over time. The optimal shrinkage temperature of collagen has been cited as
57–61°C; however, contraction is in actuality determined by a combination
of temperature and exposure time. For every 5°C decrease in temperature, a
tenfold increase in exposure time is needed to achieve an equivalent amount
of collagen contraction.
The other main mechanism in skin rejuvenation is a secondary wound
healing response that produces dermal remodeling over time. The wound
healing response entails activation of fibroblasts to increase deposition of
type I collagen and encouraging collagen reorganization into parallel arrays
of compact fibrils.

Variables that Affect RF Penetration
With radiofrequency technologies, the depth of energy penetration depends

on the configuration of the electrodes (i.e. either monopolar or bipolar), type
of tissue serving as the conduction medium (i.e. fat, blood, skin), temperature,
and the frequency of the electrical current applied.
Tissue is made up of multiple layers, which have different resistances to
the movement of radiofrequency energy with the dermal tissue with higher
impedance being more susceptible to heating. As a thumb rule fat, bone,
and dry skin tend to have low conductivities, thus the current tends to flow
around these structures rather than through them. Wet skin has a higher
electrical conductivity allowing greater penetration of current. This is the
reason why improved results are seen with generous amounts of coupling
fluid and increased hydration of skin. The structure of each individual’s tissue
(dermal thickness, fat thickness, fibrous septae, number and size of adnexal
structures) all play a role in determining impedance, heat perception, and
total deposited energy despite otherwise equal parameters.
Temperature also influences tissue conductivity and the distribution
of electrical current. Generally, every 1°C increase in temperature lowers
the skin impedance by 2%. Surface cooling will increase resistance to the


300  Lasers in Dermatological Practice

electrical field near the epidermis, driving the radiofrequency current
into the tissue and increasing the penetration depth. In addition, target
structures that have been pre-warmed with optical energy will, in theory,
have greater conductivity, less resistance, and greater selective heating by
the radiofrequency current. This is the advantage of hybrid skin-tightening
devices that use a combined approach of light and radiofrequency energy
together giving synergistic results.

Monopolar Devices

Monopolar devices may be delivered in a static or stamped mode in which
a short 1- to 2-second cycle is delivered while the handpiece is held in
place (Thermage, Solta Medical, Hayward, CA). Alternatively, monopolar
RF may be delivered in a dynamic or a continuous pulse with constant
rotation of the handpiece (Exilis, BTL, Prague, Czech Republic). In the static,
stamped method, a single pulse is delivered; the handpiece is then moved
to an adjacent marked area and fired again. This technique is performed for
hundreds of pulses until a premarked area is treated. Each pulse is measured
for temperature while spray cooling is applied so that a skin temperature of
45o C is not exceeded.
With dynamic monopolar RF, the handpiece is continuously moved
and specific areas of laxity can be targeted in a relatively short time to a
final temperature that is monitored by continuous surface temperature
measurements.

Thermage
It was the first nonsurgical treatment of periorbital skin laxity and rhytides
approved by the FDA and has since become a common technique for treating
aging skin (mid-face, cheeks, jaw line, neck, brows, abdomen, legs, and
thighs).
Thermage has been backed by a strong research and development; and
now in its third generation, it has evolved into an extremely sophisticated
device. The first generation device, was called thermacool NXT device which
employed 400, 600 and 900 REP (Radiofrequency  Energy Pulse) disposable
tips with a heat and cooling sensation.
The next level is the Thermage CPT, which has some features that make it
superior to the previous NXT (Figs 8.2A and B).
1. Redesigned tip, which improves uniformity of heating and increases the
total area of skin being effectively heated.
2. Comfort software intended to simulate transcutaneous electrical nerve

stimulation (TENS) pain reduction therapy. The TENS therapy for pain
management is based on the principle that when electrical current is
delivered through the skin, electricity stimulates nerves in the affected


Nonsurgical Tightening  301

Fig. 8.2A: Overview of the ‘Thermage’ device

Fig. 8.2B: A closer look at the components of ‘Thermage’

area and sends signals to the brain that scramble normal pain perception.
In effect, the pulsed behavior of the radiofrequency interwoven with
cooling bursts improves patient comfort.
3. Vibration based on the gate control theory of pain mitigation. The new
thermage CPT handpiece vibrates the tips in order to mitigate discomfort.
This Thermage solution here is based on the gate theory by Melzack and
Wall, which states that nerve fibers carrying pain to the spinal cord can
have their input modified at the spinal cord before transmission to the
brain, in this case by the vibration.


302  Lasers in Dermatological Practice

CPT (Comfort Pulse Technology) system came with features that
maximized thermal distribution and patient comfort both thereby
giving better tightening and contouring (Fig. 8.2C). The third generation
thermage employs the same vibration delivery module but with the new
total tip which has even more homogeneous three-dimensional skin
tightening. These variously sized tips depend mostly on the anatomical

area being treated, as larger tips cover a larger area of skin. For example,
a 1.5 cm 2 tip should be sufficient for the treatment of the face and neck.

Mechanism of Tissue Heating
The mechanism of tissue heating through the use of monopolar
radiofrequency   in thermage is unique (Fig. 8.3). As in conventional RF
devices, the tissue heat is generated based on the tissue’s natural resistance to
the movement of ions with the RF field but the difference lies in the method
of coupling the RF to the skin. In thermage, a capacitive coupling membrane
is used, which transforms RF to a volumetric tissue heating device rather
than a single point heating source as in standard RF devices. This allows
energy to be distributed over a three-dimensional volume of dermal tissue
while protecting the epidermis (Fig. 8.4). The use of capacitive rather than
conductive coupling is important because it allows the energy to be dispersed
across a surface to create a zone of tissue heating. With conductive coupling,
the energy is concentrated at the tip of the electrode, resulting in increased
heating at the contact surface and an increased risk of epidermal injury.

Fig. 8.2C: A comparison of third generation RF with the conventional RF


Nonsurgical Tightening  303

Fig. 8.3: A depiction of the depth of penetration of ‘Thermage’

Fig. 8.4: Difference in the heat generation of ‘Thermage’ and other RF machines

Thermage heats tissue more deeply and to higher temperatures than
other technologies. Temperatures are higher by 3–4° and deep heating means
that the heat dwells longer in the tissue.

The treatment protocol involves marking  square grids on the area to be
treated so that the requisite amount of overlap be done to ensure complete
coverage. The tip delivers monopolar radiofrequency to the lower layers of
the skin while protecting the epidermis with cryogenic cooling. With the new
total tip technology, thermage tightens and smoothens close to the surface
and contours deeply (Figs 8.5A and B).
Although, delivering higher energies translates to better results, it is not
meant to be an extremely painful or uncomfortable treatment, especially
since pain threshold is relative. One may be extremely comfortable with a
treatment energy of 4.5 while another may be uncomfortable with an energy


304  Lasers in Dermatological Practice

A

B

Figs 8.5A and B: A customized grid is placed to accurately localize treatment doses

of 3.5. Most treatment protocols across the world follow an algorithm of
multiple passes and moderate energies.

Treatment
Patient Selection
Suitable Candidates: Anyone between the ages of 30 and 60 years is a
suitable candidate for the face. For body treatments, anyone from 25 years
onward with a loose sagging skin or cellulite is suitable.

Exclusion Criterion

Although, Thermage is an extremely safe treatment there are a few absolute
and relative contraindications.
Absolute
¾¾ Pacemakers
¾¾ Defibrillators
¾¾ Pregnancy
¾¾ History of skin cancer, radiation therapy or metal implant in the
treatment area.


Nonsurgical Tightening  305

Relative
¾¾ History of diabetes, collagen disorders and congestive heart disease
¾¾ Patients on blood thinners
¾¾ Patients on oral retinoids
¾¾ Recent filler treatments
¾¾ History of neurological disorders.
Photography: The importance of photographic documentation in all
aesthetic treatments cannot be overemphasized. In Thermage, the results
are subtle and subjective improvement cannot always be appreciated by the
patient so before and after it is helpful to assess results for both the patient
and the doctors.
Anesthesia: The protocol dictates that anesthesia is not required since a
feedback on the pain sensation is important to minimize risk of burns. Also
topical anesthesia does take away from the heat or pain sensation much since
the heat penetration is deep.

Procedure
Treatment Energy

The treating physician must control the amount of radiofrequency energy
balancing patient comfort with optimal results since topical anesthesia is not
utilized for the procedure. The heat sensation from a single pulse treatment
lasts from 2–7 seconds. Treatment parameters vary across clinics and study
groups, but in general the previous higher energy, fewer pass practice has
now shifted to lower energy and higher pass protocols in order to increase
efficiency, tolerability, and safety.
Before treatment is initiated, coupling fluid should be applied generously
to the area. Then, following the low energy, high pass protocol, RF energy
should be applied. Initially, it is helpful for the practitioner to make use of
the company-supplied grid that is applied to the skin prior to treatment. The
grid shows exactly where the handpiece tip should be placed for adequate
treatment (Figs 8.5A and B). As an additional fail-safe, the tip must be in
complete contact with the skin or an error message will be displayed. This
ensures that the cooling tip will prevent epidermal disruption.

Treatment Areas
Thermage is primarily used for skin tightening on the face particularly the
jawline, hooding of the eyelids, back of the hands, abdomen, thighs and
upper arms. The best results are seen on the face. The results in the neck are
suboptimal because the skin of the neck is very thin, so delivery of adequate
energy for optimal results is not possible.


306  Lasers in Dermatological Practice

Post-care
There is no specific post-care advised following Thermage.

Side Effects

Except for being an expensive treatment because of the disposable tip costs
involved, a Thermage treatment done in trained hands remains an extremely
safe treatment with no side effects whatsoever. Thus, it has managed to stand
the test of time and withstand competition with all the multiple technologies
available.

Results
Initially for the face two passes at 107 J, followed by three or more passes at
83 J was administered. Extra care is given to the neck region, so only 3 or 4
total passes are made at an energy level of 83 J. Moreover, it was noted that
multiple treatments yield significantly better results than a single treatment
of the nasolabial folds. It is important to continuously assess the patient
for signs of discomfort, swelling, and skin tightening during the procedure.
Another regimen as proposed by Weiss et al. is a multiple passé regimen with
fluences of 74 to 130 J/cm2 using a 1.0-, 1.5-, or 3.0-cm2 tip.
In 2006, Dover and colleagues compared the original single-pass, highenergy technique with the updated low-energy, multiple-pass technique
using immediate tissue tightening as a real-time end point. With the original
treatment algorithm, 26% of patients saw immediate tightening, 54% observed
skin tightening at 6 months, and 45% found the procedure overly painful.
With the updated protocol, 87% had immediate tissue tightening, 92% had
some degree of tightening at 6 months, only 5% found the procedure overly
painful, and 94% stated the procedure matched their expectations. According
to several authors, a good clinical response remains the most useful cut-off
guide for treatment.
Generally, improvements are immediately visible and continue for up to
6 months. One of the key features of a Thermage treatment is the preventative
aging aspect that is not possible with any injectable treatment. The results can
easily last up to 2 years.
Quantifiable changes have been seen in brow and superior palpebral
crease elevation as well as in the peak angle of the eyebrow and jowl surface

area.

Site Specific Improvement
1.Face: The effect is a smoothning and tightening of the skin. There is a
improved jawline contouring and sagging of the skin under the chin.


Nonsurgical Tightening  307

The Figuer 8.6 reveals softening of wrinkles around the mouth, eyes, and
forehead.
2.Eyes: There is a pronounced lifting of the eyelids (Fig. 8.7). Thermage is
probably the only nonsurgical procedure that smoothens and tightens
the skin and decreases wrinkles and hooding in the eye area without
surgery, injections or downtime. Treatment results are younger looking,
more lifted eyes that look less tired. There is reduction in under eye
bulges and improved laxity. Eyes are protected during the procedure

Fig. 8.6: A marked improvement in the forehead lines

Fig. 8.7: A pre- and postoperative photograph showing the marked improvement in
wrinkles around the eyes


308  Lasers in Dermatological Practice

with small, plastic eye shields. Suitable candidates for thermage for
eyes are those with moderate hooding, crow’s feet, eyelid laxity and/or
under-eye bags.
3.Body: Thermage for the body procedures improve skin tone and texture

while effectively smoothing, tightening and contouring skin for an overall
naturally younger looking appearance. With little to no downtime,
thermage for the body treatments tighten and renew the skin’s collagen
deep down, through all three layers of skin—the epidermis, dermis
and subcutaneous (fat) layer. The treatment is ideal for arms, abdomen
(commonly used  post-pregnancy and after liposuction or weight loss),
and thighs. It remains the nonsurgical treatment of choice for loose lax
skin on the body areas (Fig. 8.8).

Cellulite
Thermage is FDA approved for cellulite. Although it is widely used with a
separate cellulite tip, in the authors experience the result’s are variable.

Acne
In addition to skin tightening, monopolar RF has also been used to treat active
cystic acne to inhibit sebaceous activity and promote dermal contouring. A
study (Ruiz-Esparza J 2003) including 22 patients with moderate to severe
active cystic acne reported improvement with the use of stamped monopolar
RF. Patients were treated in 1 to 3 sessions using 65 to 103 J/cm2. A 75%
reduction in the active acne lesion count was seen in 92% of patients, and a
25% to 50% reduction occurred in 9% of patients. Often a decrease in active
lesions was accompanied by the improvement of underlying scarring. These
results have not been duplicated in other studies.

Fig. 8.8 : Tightening of the loose skin on the abdomen


Nonsurgical Tightening  309

EXILIS Elite Device

A novel RF dynamic monopolar device, the Exilis, is a device that combines
focused monopolar RF delivery with several built-in safety features, including
Peltier cooling. The Exilis system delivers the energy through two different
hand applicators, one designed for the face and one designed for the body.
The goal of treatment is to raise the surface temperature to 40°C to 42°C for 4 to
5 minutes for each region treated. When this temperature is reached, patients
feel a comfortably warm sensation. The handpiece is in continuous motion
so that the areas of skin with the most laxity can be specifically targeted. This
treatment has been termed ‘dynamic monopolar RF’. Additionally, Peltier
cooling can be adjusted up or down to allow targeting of skin or subcutaneous
tissue. For example, to drive heating more deeply, the skin is cooled and
protected allowing heat to reach into subcutaneous fat. Alternatively, to get
the maximum effect on skin laxity, cooling is turned off and heating of the
skin occurs very quickly with a minimal effect on subcutaneous fat.

Bipolar RF
In this method, the RF travels from the positive to the negative pole,
which is typically between 2 poles built into the handpiece. With a specific
distance between the electrodes, the depth of penetration and heating is
predetermined by the spacing of the electrodes and is typically confined to
within 1 to 4 mm of the skin surface (Fig. 8.9). It is commonly stated that the
depth of penetration is half the distance between the electrodes, but there is
very little evidence to support this assertion.
The ‘Raylife’ radiofrequency is bipolar parallel that uses a handpiece that
has two electrodes positioned inside it.
The addition of the vacuum function generates continuous or pulsed
suction of tissue with the passage of electromagnetic waves only on the
selected target area. These waves pass from one electrode to another and
when they cross the dermis they activate the mechanism of denaturizing the
collagen. The Coolstar, water cooling function on the tissue, determines a

protective action on the epidermis making the treatment extremely pleasant
and safe (Fig. 8.10).
Bipolar RF is not as penetrating as monopolar RF, so it is not as painful but
is often combined with another energy source to increase its efficacy. There
are multiple variations of the bipolar RF concept and these are as follows
(Table 8.2):
1. Fractional or fractionated RF constructed of mini-bipolar electrodes
(eMatrix, e2, Syneron/Candela, Wayland, MA).
2. Bipolar insulated needle electrodes, which are mechanically inserted
into the dermis (ePrime, Syneron/Candela).


310  Lasers in Dermatological Practice

Fig. 8.9: Illustration of bipolar radiofrequency, ‘L’ handpiece (inactive and active)
(Asclepion Laser Technologies, GmbH)

Fig. 8.10: Advantages of bipolar RF (Asclepion Laser Technologies, GmbH)


Nonsurgical Tightening  311

3.Bipolar RF combined with other modalities, including diode laser
or intense pulsed light (Polaris, Aurora, and Velasmooth, Syneron/
Candela).
4. Multiple bipolar electrodes at different distances apart firing sequentially
to achieve different depths (EndyMed PRO, EndyMedMedical Ltd,
Caesarea, Israel).
5. Bipolar RF with vacuum to control depth of penetration called functional
aspiration controlled electrothermal stimulation (Aluma, Lumenis Inc,

San Jose, CA).
6. Other variations include magnetic pulse and combinations with IR.
The major disadvantage to bipolar radiofrequency is that the energy
does not penetrate very deep into the skin. Also, it is believed that bipolar
radiofrequency is unable to produce a uniform, volumetric heating response
comparable to monopolar radiofrequency. When bipolar radiofrequency
devices are combined with other light-based technologies, which is the case
in most situations, it is then difficult to assess exactly how large a role bipolar
radiofrequency plays in the clinical outcomes of such treatments.

Aluma
The Aluma is a bipolar RF plus vacuum device that is composed of an RF
generator, a handpiece, and a tip with 2 parallel electrodes. When the hand
piece with the tip is placed perpendicular to the surface of the skin, the system
produces a vacuum, which suctions a small area of skin. The skin becomes a
U-shaped area with epidermis on both sides and the dermis and connective
tissue in the middle. The design is to allow the energy emitted to reach the
middle and deep dermis.
This is also called as ‘FACES’ (functional aspiration controlled electro­
thermal stimulation) technology. Non-target structures such as muscle,
fascia, and bone are avoided. The theory is that this may help to overcome
the depth limitations inherent in bipolar radiofrequency technology by
bringing the target tissue closer to the electrodes. Less overall energy may
also be required for an effective treatment. It has also been hypothesized that
increased blood flow and mechanical stress of fibroblasts from the vacuum
suction may lead to increased collagen formation. Vacuum technology has
the added benefit of helping to reduce procedure discomfort.
In a pilot study of 46 adults, Gold found significant improvements in skin
texture, indicating a shift from moderate to mild elastosis. There was a shortterm tightening effect due to collagen contraction followed by a gradual, longterm improvement due to the wound healing response and neocollagenesis.
Importantly although subjects were generally pleased with the treatment

outcome, their satisfaction levels declined somewhat during the follow-up
period.


312  Lasers in Dermatological Practice

eMatrix
Fractional RF is another form of bipolar RF delivery with mini-electrodes. The
concept is that RF is omnidirectional so that dots of RF spread out from the
point of contact in comparison with laser in which the energy is attenuated in
a sharp fashion in interaction with tissue.
Fractional RF has been used mainly for skin rejuvenation. Less than
1-mm thermal injuries are formed in a patterned fractional array directly to
the reticular dermis. The area directly in contact with and below the array of
microneedles or electrodes is selectively heated while the areas between the
targeted areas are left intact.

ELOS
Combined Electrical and Optical Energy
The basic principle is that these skin-tightening devices combines radio­
frequency energy with optical energy from laser or light sources. The currently
available combined electrical and optical energy devices include the Galaxy,
Aurora, Polaris, and ReFirme systems (Syneron Medical Ltd, Yokneam,
Israel).
They have a theoretical advantage of acting synergistically to generate
heat. As discussed above when the target structures have been pre-warmed
with optical energy they will have greater conductivity, less resistance, and
greater selective heating by the radiofrequency current. No grounding pad is
required as the current flows between the electrodes rather than throughout
the remainder of the body as with monopolar systems. There is a potential

side effect in “tissue arcing”, which results in tissue burns and possible scar
formation. Proper technique will help avoid the issue as arcing has been
associated with the handpiece not being properly placed in contact with the
skin.
The technology has been used in hair removal, wrinkle reduction, skin
tightening, and the treatment of both pigment and vascular disorders. The
premise is that less radiofrequency energy is ultimately needed for proper
collagen denaturation and remodeling.
The ReFirme ST system produces only mild improvement of facial laxity in
Asians (Yu et al.) without serious adverse effects, but still meets high patient
expectations. More enduring studies are necessary to determine the longterm tissue tightening effects of this device.
A study by Doshi and Alster in 20 patients (skin phototypes I–III) with
mild-to-moderate rhytides and skin laxity with the Polaris WR combination
RF and diode laser device found only modest improvement of facial
rhytides.


Nonsurgical Tightening  313

Hybrid Monopolar and Bipolar Radiofrequency
The first system to combine monopolar and bipolar radiofrequency in one
device was the Accent (Alma Lasers, Buffalo Grove, IL). The theory behind
using both types of radiofrequency is to deliver different depths of current to
the skin. The bipolar electrode handpiece allows for more superficial, localized
(non-volumetric) heating based on tissue resistance to the radiofrequency
conductive current. The monopolar electrode handpiece targets deeper,
volumetric heating via the rotational movement of water molecules in the
alternating current of the electromagnetic field.
Therefore, the monopolar handpiece is used to treat the forehead, cheeks,
jawline, and neck while the bipolar handpiece is used to treat the glabella,

lateral periorbital area, upper lip and chin, and leg.
In 2007, Friedman and Gilead studied this device and found that although
the Accent system is effective in the treatment of wrinkles and lax skin,
younger individuals may see a greater benefit.

Pelleve Device (Ellman International, Oceanside, NY)
This has a dual monopolar and bipolar radiofrequency-based surgical unit
normally used for tissue cutting and coagulation to make it suitable for skintightening procedures. The system works with the use of reusable probes that
are plugged into the system and applied over the skin in a circular pattern
to heat the subdermal tissue. A chilled coupling gel is used to assure proper
coupling between the electrode and the patient and to help protect the
epidermis. As with other skin-tightening devices, the gentle heating induces
collagen denaturation, contraction, and subsequent synthesis. Repeat
treatments have been shown to improve the appearance of wrinkles and skin
laxity, but results are somewhat limited due to the discrete amount of energy
applied. Early protocols recommended 8-weekly treatments for best results,
but the treatment paradigm has since been revised to two treatments spaced
1 month apart, with some patients requiring an additional treatment.

Unipolar RF
Another form of delivery is unipolar in which there is one electrode, no
grounding pad, and a large field of RF emitted in an omnidirectional
field around the single electrode. This form is analogous to a radio tower
broadcasting signals in all directions.

The Accent (Alma Lasers, Inc, Ft Lauderdale, FL)
The Accent RF system is designed for continuous skin contact using two
handpieces: the unipolar to deliver RF energy to the subcutaneous adipose

314  Lasers in Dermatological Practice

tissue for volumetric heating and the bipolar to deliver RF energy to the
dermis for nonvolumetric heating.
It uses both unipolar and bipolar RF and delivers different depths of RF
current to the skin, theoretically bipolar for more superficial heating and
unipolar for deeper dermal heating. Several clinical trials describe its use in
reducing the appearance of cellulite and its effects on tissue tightening.

Multipolar Noncontact RF Device
Vanquish (BTL Aesthetics, Prague, Czech Republic)
Previously discussed RF devices are operator dependent. This device has
been designed for a contactless deep-tissue thermal-energy application. The
applicator-generator circuitry is engineered to selectively deliver the energy
to the tissue layer with specific impedance. This high-frequency system
focuses energy specifically into the adipose tissue, while limiting delivery to
the epidermis, dermis, and muscles. Animal studies have shown a 70% fat
reduction in the treated abdominal area. Proportionate results have been
seen in humans also.

Conclusion
There are certain important rules that determine results with RF:
1. Though the early results are marked, the late results are difficult to
judge objectively. This makes an excellent photographic documentation
essential. This is because delayed neocollagenesis and long-term woundhealing response is an important aspect of RF therapy and subjects may
have difficulty, accurately remembering the exact condition of their skin
pre-treatment, particularly when 6 or more months have passed.
2. Young patients respond best to therapy. This can be partly due to the
replacement of heat-labile collagen bonds by irreducible multivalent
cross-links as patients age, making older skin less susceptible to heatinduced tissue tightening.

Infrared light devices
1. Broadband infrared light in the range of 800 to 1,800 nm, has also been
utilized for nonablative tissue tightening. The first such light-based
system was the Titan (Cutera, Brisbane, CA). It utilizes light energy in
the range of 1,100 to 1,800 nm to target water as a chromophore, causing
collagen denaturation and ultimately collagen remodeling and tissue
tightening. Studies on this device have shown that minimal to excellent
results can be obtained with immediate skin tightening, but clinical
skin tightening does not always correlate with immediate positive


Nonsurgical Tightening  315

histological findings. This is explained by the fact that full clinical effect
may take weeks or months to be demonstrated owing to a secondary
wound healing response. (Ruiz-Esparza  J, 2006 and Zelickson  B). A
lower fluence range of 30–40 J/cm2, 2–3 treatments, 1–2 passes, and extra
passes on areas that need immediate contraction or along vector lines
yielded best results.
2.The StarLux IR (Palomar Medical Technologies, Burlington, MA)
delivers fractionated energy through the handpiece of the device at a
wavelength range of 850 to 1,350 nm, which also targets water as the
principal chromophore. Multiple treatments are required for optimal
results.
3. The SkinTyte device (Sciton, Palo Alto, CA) utilizes light at a wavelength
range of 800 to 1,400 nm.
4.Other laser wavelengths that have been used for tissue tightening
include the 1,064 nm and 1,320 nm wavelengths. The chromophores for
the 1,064 nm wavelength, in decreasing order, are melanin, hemoglobin

and water, and the primary chromophore for the 1,320 nm wavelength is
water.
Though studies (Taylor and Prokopenko, 2005) have shown results better
than a monopolar radiofrequency system, some authors point out that
(Key, 2007) that the 1,064 nm improves the lower face, more than the
upper face. The mild improvemnet noted by Trelles (2001) using a 1,320
nm laser system shows that combining laser treatment with parallel
epidermal treatment may yield better results and achieve higher patient
satisfaction.

Ultrasound devices
High-intensity focused ultrasound (HIFU) is the most recent player to enter
the skin-tightening technology realm.
The basic concept being that the intense ultrasound field vibrates tissue
thus the consequent friction created between molecules causes them to
absorb mechanical energy and leading to secondary generation of heat.
Intense focused ultrasound for skin-tightening applications uses short,
millisecond pulses with a frequency in the megahertz (MHz) domain, rather
than kilohertz (kHz) as is used in traditional HIFU, to avoid cavitational
processes. Intense focused ultrasound also uses significantly lower energies
than traditional HIFU, 0.5–10 J versus 100 J, which allows thermal tissue
changes without gross necrosis.
The main advantage to focused ultrasound is the potential for greater
depth of skin changes than other technologies with the added benefit of
precisely controlled, focal tissue injury. Ultrasound energy is able to target
deeper structures in a select, to ocused fashion without secondary scatter and
absorption in the dermis and epidermis. The first intense focused ultrasound


316  Lasers in Dermatological Practice

device on the market is the Ulthera system Ulthera Inc., Mesa, AZ) and is
covered in detail in a following chapter.

Conclusion
Nonsurgical skin tightening is best suited for patients with mild-to-moderate
laxity. Thus, cases with laxity of the aponeurotic system are not candidates
for this therapy. Combination therapy is the ideal approach in most cases.
A suggested approach in a patient desirous of a brow lift and a jawline
definition may be a combination of botox to the orbicularis oculi and
platysma in addition to skin tightening. Fillers can be used in the mid face,
brow/temples and jawline.
The key to success is ideal patient selection and management of
expectations. As there remains a lack of an FDA-approved method for
measuring skin tightening, most of the results are based on before and after
photos. A few assessment scales are given in Table 8.3 and 8.4, which can help
the clinician objectively assess results. Large-scale randomized controlled
trials are still necessary to determine optimal treatment parameters for most
of the newer bipolar devices and USG.

Table 8.3 The Fitzpatrick Wrinkle Classification System
Class

Wrinkling

Score

Degree of elastosis

I

Fine wrinkles

1–3

Mild (fine textural changes with
subtly accentuated skin lines)

II

1.Fine-to-moderate depth
wrinkles
2. Moderate number of lines

4–6

Moderate (distinct popular elastosis
[individual papules with yellow
translucency under direct lighting]
and dyschromia)

III

1. Fine-to-deep Wrinkles
2. Numerous lines
3. With or without redundant
skin folds

7–9

Severe (multipapular and confluent
elastosis [thickened yellow and
pallid] approaching or consistent
with cutis rhomboidalis)

Table 8.4 The Leal Laxity Classification System
Laxity

Description

A

Superficial laxity limited to the skin

B

Structural laxity involving
subcutaneous tissue

AB

Combined superficial and structural
laxity


Nonsurgical Tightening  317

Bibliography
1. Abraham MT, Chiang SK, Keller GS, Rawnsley JD, Blackwell KE, Elashoff DA.
Clinical evaluation of non-ablative radiofrequency facial rejuvenation. J Cosmet

Laser Ther. 2004;6:136-44
2. Alster TS, Tanzi E. Improvement of neck and cheek laxity with a non-ablative
radiofrequency device; a lifting experience. Dermatol Surg. 2004;30:503-7.
3. Beasley KL, Weiss RA. Radiofrequency in cosmetic dermatology. Dermatol Clin.
2014;32(1):79-90.
4. Biesman BS, Baker SS, Carruthers J, Leal Silva H, Holloman EL. Monopolar
radiofrequency treatment of human eyelids: A prospective, multicenter, efficacy
trial. Lasers Surg Med. 2006;38:890-8.
5. Bogle MA, Kaminer MS. Non surgical Skin tightening. In: Lasers and Lights:
Procedures in Cosmetic Dermatology, 3rd edition by Hruza GJ and Avram MM.
2013.
6. Doshi SN, Alster TS. Combination radiofrequency and diode laser for
treatment of facial rhytides and skin laxity. J Cosmet Laser Ther. 2005;7(1):11-5.
7. Dover JS, Zelickson B and the 14-Physician multispecialty consensus panel:
Results of a survey of 5,700 patient monopolar radiofrequency facial skin
tightening treatments: assessment of a low-energy multiple-pass technique
leading to a clinical end point algorithm. Dermatologic Surgery. 2007;33:900-7.
8. Fitzpatrick RE, Geronemus RG, Goldberg DJ, Kaminer MS, Kilmer SL, RuizEsparza J. Multicenter study of non-invasive radiofrequency for periorbital tissue
tightening. Lasers Surg Med. In press
9. Friedman DJ, Gilead LT. The use of hybrid radiofrequency device for the treatment
of rhytides and lax skin. Dermatol Surg. 2007;33(5):543-51.
10. Gold MH. Update on tissue tightening. Journal of Clinical and Aesthetic.
Dermatology. 2010;3:36-41.
11. Key DJ. Single-treatment skin tightening by RF and long-pulsed, 1064-nm Nd :
YAG laser compared. Lasers in Surgery and Medicine. 2007;2:16-75.
12. Lolis MS, Goldberg DJ. Radiofrequency in cosmetic dermatology: a review.
Dermatol Surg. 2012;38(11):1765-76.
13. Narins DJ, Narins RS. Non–surgical radiofrequency facelift. J Drugs Dermatol.
2003;2:495-500.
14. Ruiz-Esparza J, Gomez JB. Nonablative radiofrequency for active acne vulgaris:

the use of deep dermal heat in the treatment of moderate to severe active acne
vulgaris (thermotherapy): a report of 22 patients. Dermatol Surg. 2003;29(4):
333-9.
15. Ruiz-Esparza J, Gomez JB. The medical facelift: a non-invasive, non-surgical
approach to tissue tightening in facial skin using non-ablative radiofrequency.
Dermatol Surg. 2003;29:325-32.
16. Ruiz-Esparza J. Painless, nonablative, immediate skin contraction induced
by low-fluence irradiation with new infrared device: a report of 25 patients.
Dermatologic Surgery. 2006;32(5):601-10.
17. Taylor MB, Prokopenko I Split-face comparison of RF versus long-pulse Nd:YAG
treatment of facial laxity. Journal of Cosmetic and Laser Therapy. 2006;8:17-12.


318  Lasers in Dermatological Practice
18. Trelles MA, Allones I, Luna R. Facial rejuvenation with a nonablative 1320-nm
Nd:YAG laser: a preliminary clinical and histologic evaluation. Dermatologic
Surgery. 2001;27:111-6.
19. Wall MS, Deng XH, Torzilli PA, Doty SB, O’Brien SJ, Warren RF. Thermal
modification of collagen. J Shoulder Elbow Surg. 1993;8:339-44.
20. Weiss RA, Weiss MA, Munavalli G, Beasley KL. Monopolar radiofrequency facial
tightening: a retrospective analysis of efficacy and safety in over 600 treatments. J
Drugs Dermatol. 2006;5(8):707-12.
21.Yu CS, Yeung CK, Shek SY, et al. Combined infrared light and bipolar
radiofrequency for skin tightening in Asians. Lasers Surg Med. 2007;39:471-5.
22. Zelickson B, Ross V, Kist D, et al. Ultrastructural effects of an infrared handpiece
on forehead and abdominal skin. Dermatologic Surgery. 2006;32:897-901.