Multicenter study of noninvasive radiofrequency for periorbital tissue tightening

Radiofrequency treatment of vaginal laxity after vaginal delivery: nonsurgical vaginal tightening

INTRODUCTION

All women who have given birth vaginally experience stretching of their vaginal tissue. Long-term physical and psychological consequences may occur, including loss of sensation and sexual dissatisfaction. One significant issue is the laxity of the vaginal introitus.

AIM

To evaluate safety and tolerability of nonsurgical radiofrequency (RF) thermal therapy for treatment of laxity of the vaginal introitus after vaginal delivery. We also explored the utility of self-report questionnaires in assessing subjective effectiveness of this device.

METHODS

Pilot study to treat 24 women (25-44 years) once using reverse gradient RF energy (75-90 joules/cm(2) ), delivered through the vaginal mucosa. Post-treatment assessments were at 10 days, 1, 3, and 6 months.

MAIN OUTCOME MEASURES

Pelvic examinations and adverse event reports to assess safety. The author modified Female Sexual Function Index (mv-FSFI) and Female Sexual Distress Scale-Revised (FSDS-R), Vaginal Laxity and Sexual Satisfaction Questionnaires (designed for this study) to evaluate both safety and effectiveness, and the Global Response Assessment to assess treatment responses.

RESULTS

No adverse events were reported; no topical anesthetics were required. Self-reported vaginal tightness improved in 67% of subjects at one month post-treatment; in 87% at 6 months (P<0.001). Mean sexual function scores improved: mv-FSFI total score before treatment was 27.6 ± 3.6, increasing to 32.0 ± 3.0 at 6 months (P < 0.001); FSDS-R score before treatment was 13.6 ± 8.7, declining to 4.3 ± 5.0 at month 6 post-treatment (P < 0.001). Twelve of 24 women who expressed diminished sexual satisfaction following their delivery; all reported sustained improvements on SSQ at 6 months after treatment (P = 0.002).

CONCLUSION

The RF treatment was well tolerated and showed an excellent 6-month safety profile in this pilot study. Responses to the questionnaires suggest subjective improvement in self-reported vaginal tightness, sexual function and decreased sexual distress. These findings warrant further study.

Nonablative facelift in Indian skin with superpulsed radiofrequency

AIMS

To evaluate the effect of nonablative superpulsed radiofrequency used for skin tightening and improvement of skin folds in Indian patients.

SETTINGS AND DESIGN

One hundred patients in the age group of 35-65 years with laxity of skin over face and neck were taken up for study using superpulse radiofrequency.

METHODS AND MATERIALS

Superpulsed radiofrequency is a biterminal, monopolar device which delivers current at the frequency of 1.75 MHz. In this study, current was delivered to the tissue with a capacitive electrode with a diameter of 25 mm. Power of 100-120 W, frequency of 18 Hz and pulse width of 50 ms was used.

STATISTICAL ANALYSIS USED

Chi-square test, nonparametric Friedman test.

RESULTS

Evaluation was done by two independent observers on the basis of comparative photographs taken before treatment and then monthly after treatment for up to 6 months. A quartile grading scale was used. Patient satisfaction scores matched the clinical improvements observed. Ninety four patients completed a 6 month follow up. The age groups taken were 31-40 years, 41-50 years, 51-60 years, and >60 years and various areas were studied. The difference in improvement in all areas except glabellar folds across all age groups was found to be statistically significant.

CONCLUSIONS

Nonablative face lift with a superpulsed radiofrequency machine is a safe, convenient and quick office procedure with excellent cosmetic results. It is noninvasive and there is no downtime. It can be used in all skin types and is safe on Indian skin. Longterm studies of effect of nonablative radiofrequency treatment on Indian skin is required.

Laser treatment of dark skin: an updated review

The growing diversification of the patient population coupled with the increasing demand for cosmetic laser rejuvenation has highlighted the need to develop cutaneous laser systems and establish treatment protocols for patients with a wide range of skin conditions and phototypes. Recent technologic advancements have provided viable treatment options to achieve clinical outcomes that were previously only attainable in patients with lighter skin tones. This review provides an updated discussion of the range of laser treatments available for pigmented skin and sets the stage for further advancements. Pigment-specific laser technology with green, red, or near-infrared light targets a variety of pigmented lesions such as lentigines, ephelides, café-au-lait macules, and melanocytic nevi as well as tattoos and unwanted hair. Short-pulsed alexandrite, ruby, and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are used for pigmented lesions and tattoos, whereas their longer pulse-width laser counterparts are used for laser-assisted hair removal. Vascular lesions and hypertrophic scars can be treated with a variety of vascular-specific lasers, but it is the pulsed dye laser (PDL) that has long been the gold standard treatment for these lesions due to its high specificity for hemoglobin and its ability to improve skin surface texture in children and adults. Laser skin resurfacing techniques for photodamaged skin and atrophic scars have been optimized with fractional technology to produce excellent clinical outcomes and minimal complication risks. Radiofrequency and nonablative lasers are also used to provide skin tightening and collagen remodeling with virtually no postoperative recovery.

Radiofrequency devices for body shaping: a review and study of 12 patients

Radiofrequency (RF) devices such as ThermaCool TC (Solta Medical Inc., Hayward, CA) offer a nonablative and noninvasive treatment option for unwanted skin concerns of the head, neck, and body. Relatively fewer studies address RF treatment on the body when compared with the head and neck. The purpose of this report is to investigate the use of the ThermaCool TC system with the novel Thermage Multiplex Tip for the enhancement of body shape. Additionally, this report will review the literature of RF technology with a concentration on body shaping. Twelve subjects underwent ThermaCool TC treatments using the Thermage Multiplex Tip. Waist circumference, standardized photographs, skin laxity score, global aesthetic improvement score, and patient satisfaction surveys were assessed at baseline and several follow-up visits after treatment. Average waist circumference and skin laxity scores decreased after ThermaCool TC treatment, using the Thermage Multiplex Tip at follow-up visits held at 1, 2, 4, and 6 months after treatment. Global aesthetic improvement score and patient satisfaction surveys reflected these objective clinical improvements. RF devices, such as the ThermaCool TC offer a nonablative and noninvasive treatment option for unwanted skin findings of the head, neck, and body.

Ultrasound tightening of facial and neck skin: a rater-blinded prospective cohort study

BACKGROUND

Nonablative skin tightening technologies offer the prospect of reduction of wrinkles and skin sagging with minimal downtime, discomfort, and risk of adverse events. The excellent safety profile is mitigated by the limited efficacy of such procedures.

OBJECTIVE

We sought to assess the efficacy of ultrasound skin tightening for brow-lift in the context of a procedure treating the full face and neck.

METHODS

This was a rater-blinded, prospective cohort study at a dermatology clinic in an urban academic medical center. Subjects were medicated with topical anesthetic and then treated with an investigational focused intense ultrasound tightening device to the forehead, temples, cheeks, submental region, and side of neck using the following probes: 4 MHz, 4.5-mm focal depth; 7 MHz, 4.5-mm focal depth; and 7 MHz, 3.0-mm focal depth. Standardized photographs of front and side views were obtained at 2, 7, 28, 60, and 90 days; rating scales of pain, adverse events, physical findings, and patient satisfaction were also completed. Primary outcome measure was detection of improvement in paired comparison of pretreatment and posttreatment (day 90) photographs by 3 masked expert physician assessors, cosmetic and laser dermatologists, and plastic surgeons who were not authors. Second primary outcome measure was objective brow elevation as quantitated by a standard procedure using fixed landmarks. Secondary outcomes measure was patient satisfaction as measured by a questionnaire.

RESULTS

A total of 36 subjects (34 female) were enrolled, one subject dropped out, and 35 subjects were evaluated. Median age was 44 years (range 32-62). On the first primary outcome measure, 30 of 35 subjects (86%) were judged by the 3 masked experienced clinician raters to show clinically significant brow-lift 90 days after treatment (P = .00001). On the second primary outcome measure, mean value of average change in eyebrow height as assessed by measurement of photographs at 90 days was 1.7 mm.

LIMITATIONS

Limitations of this study include the inability to quantitatively measure lower face tightening because of the lack of fixed anatomic landmarks in this area.

CONCLUSION

Ultrasound appears to be a safe and effective modality for facial skin tightening. A single ultrasound treatment of the forehead produced on average brow height elevation of slightly less than 2 mm. Most treated individuals responded, commonly with accompanying transitory mild erythema and edema.

A novel radiofrequency device for the treatment of rhytides and lax skin: a pilot study

BACKGROUND

Radiofrequency devices generate electromagnetic energy to induce dermal heating to a critical temperature of about 65 degrees C, causing collagen to shrink and contract, and this provides a non-ablative means to improve rhytides and lax skin.

OBJECTIVE

To evaluate the efficacy and safety of a novel radiofrequency device (Photo Bio Care, Thailand) operating at a frequency of 1.75 MHz for the treatment of rhytides and lax skin in Asian patients.

METHODS

Six female patients (age range, 30-60 years; mean age 48 years) with class I and II facial rhytides and Fitzpatrick skin types III and IV were treated six times at intervals of 2-3 weeks. The forehead, periorbital area, cheeks and nasolabial folds were treated using the following parameters: monopolar mode, pulse duration of 5 s, frequency of 18 Hz, and power of 100 W. No preoperative anesthesia or postoperative treatment were used. The handpiece was applied to the skin in a continuous sweeping motion until the baseline skin temperature was elevated to 40 degrees C, as monitored with a laser thermometer, and this was maintained for 3 minutes. Clinical photographs were taken before, after the sixth treatment and 2 months after the last treatment. Analysis was undertaken through photographic evaluation by non-treating physicians.

RESULTS

At 2 months after the last treatment, mild to moderate (25-50%) clinical improvement was noted in all patients compared to baseline, and all patients were somewhat satisfied with the treatment. The procedure was well tolerated with no unexpected side effects. Discomfort was rated as mild and post-treatment erythema resolved within 1-2 hours.

CONCLUSION

Treatment with the radiofrequency device can result in mild to moderate clinical improvement of age-related rhytides and lax skin. The system is safe and inexpensive with no consumables required.

Combination radiofrequency and diode laser for treatment of facial rhytides and skin laxity

PURPOSE

As the demand for noninvasive procedures to address cutaneous aging issues has increased, novel nonablative lasers and radiofrequency (RF) devices have recently emerged. The objective of this study was to evaluate the safety and efficacy of a combination RF/diode laser device designed to target both skin laxity and facial rhytides. Materials and methods. Twenty patients (skin phototypes I-III) with mild to moderate rhytides and skin laxity received three treatments at 3-week intervals with a combined radiofrequency and diode laser system (Polaris WR(TM), Syneron Medical Ltd, Israel). Clinical improvement was determined through masked assessments by the treating investigator and two independent assessors after each treatment session, and at 3 and 6 months after the final treatment using a quartile grading scale (1<25%; 2 = 25-50%; 3 = 51-75%; 4>75% improvement). Patient satisfaction surveys were also obtained at end-study.

RESULTS

Modest improvement in facial rhytides was observed in the majority of patients as evidenced by investigator and independent assessor evaluations. Patient satisfaction surveys reflected the clinical improvements observed. Side effects were mild and limited to transient erythema and edema. No scarring or pigmentary alteration was seen.

CONCLUSIONS

The Polaris WR(TM), which sequentially delivers radiofrequency and diode laser energy, is safe and effective for treatment of mild to moderate facial rhytides and skin laxity. Multiple treatment sessions and laser passes were well tolerated by patients due to the minimization of individual optical and radiofrequency energies used.

Clinical evaluation of non-ablative radiofrequency facial rejuvenation

OBJECTIVE

To evaluate the clinical efficacy of non-ablative cutaneous radiofrequency (RF) facial rejuvenation.

DESIGN

Prospective study with longitudinal follow-up of a validation cohort set in an urban, private practice of an ambulatory facial plastic surgery center in southern California.

METHODS

A consecutive sample was enrolled of 35 healthy adults with moderate facial aging, manifested by skin laxity, rhytids, and ptosis (brow, midface, jowls). Following intravenous sedation anesthesia, the study area was treated with 115-144 J/cm2 using the non-ablative RF device (ThermaCool TC). The main outcome measures were the objective measurement of brow height, investigator evaluation of skin parameters, a patient satisfaction questionnaire, and standardized photography, at fixed time intervals.

RESULTS

At 12 weeks, a statistically significant increase in mean vertical brow height of 1.6-2.4 mm was observed in patients treated exclusively with the RF device (p<0.0001). All skin parameters (laxity, wrinkles, clarity, pore size) were improved. Complications and side effects were minimal. Patients were uniformly satisfied.

CONCLUSIONS

The ThermaCool TC RF system represents a promising non-invasive method of obtaining moderate facial rejuvenation in the appropriately selected patient. Long-term results are pending.

Diagnosis and management of skin resurfacing-related complications

The field of skin resurfacing is undergoing rapid evolution with many new technologies that have developed, providing more choices for physicians and patients. Knowing the potential adverse effects associated with each skin resurfacing modality is paramount in selecting the appropriate approach for each candidate, thereby minimizing complications and achieving optimal results.

Nonsurgical nonablative treatment of aging skin: radiofrequency technologies between aggressive marketing and evidence-based efficacy

The gold standard treatment for the many aesthetic aspects of aging has for many years been surgery in its many forms. However, with increasing patient demand for cosmetic rejuvenation and with the strong desire and drive by patients to attain aesthetic enhancement with minimal risk and rapid recovery, there has been a strong surge inspiring the field of nonsurgical skin rejuvenation. Traditionally, most of the nonsurgical methods have centered around those that destroy the epidermis and cause a dermal wound, with resultant dermal collagen remodeling and secondary skin tightening and rhytid improvement. Currently, there is growing interest in a wide range of nonablative interventions that, predictably, are claimed to rejuvenate skin and subcutaneous tissue "safely and effectively." Although several nonablative systems have been cleared by the U.S. Food and Drug Administration (FDA) for the purpose of skin rejuvenation and despite significant reported improvement in the appearance of signs and symptoms of photoaging by relatively noninvasive means, the clinical results have been generally less than impressive, with most subjects showing only mild improvement. The current review aims at summarizing the various nonablative methods currently in use for skin rejuvenation and to evaluate the evidence-based efficacy of a particular nonablative radiofrequency (NARF) method: monopolar radiofrequency.

Lasers and optical technologies in facial plastic surgery

Lasers and optical technologies play a significant role in aesthetic and reconstructive surgery. The unique ability of optical technologies to target specific structures and layers in tissues to effect chemical, mechanical, or thermal changes makes them a powerful tool in cutaneous rejuvenation, hair removal, fat removal, and treatment of vascular lesions such as port-wine stains, among many other procedures. With the development of adjunct techniques such as epidermal cooling, lasers and optical technologies have become more versatile and safe. The constant improvement of existing applications and the emergence of novel applications such as photodynamic therapy, nanoparticles, spectroscopy, and noninvasive imaging continue to revolutionize aesthetic medicine by offering a minimally invasive alternative to traditional surgery. In the future, therapies will be based on individualized, maximum, safe radiant exposure to deliver optimal dosimetry. Lasers and optical technologies are headed toward safer, easier, more quantifiable, and more individualized therapy.

The Asian dermatologic patient: review of common pigmentary disorders and cutaneous diseases

The Asian patient with Fitzpatrick skin types III-V is rarely highlighted in publications on cutaneous disorders or cutaneous laser surgery. However, with changing demographics, Asians will become an increasingly important group in this context. Although high melanin content confers better photoprotection, photodamage in the form of pigmentary disorders is common. Melasma, freckles, and lentigines are the epidermal disorders commonly seen, whilst nevus of Ota and acquired bilateral nevus of Ota-like macules are common dermal pigmentary disorders. Post-inflammatory hyperpigmentation (PIH) occurring after cutaneous injury remains a hallmark of skin of color. With increasing use of lasers and light sources in Asians, prevention and management of PIH is of great research interest. Bleaching agents, chemical peels, intense pulsed light (IPL) treatments, and fractional skin resurfacing have all been used with some success for the management of melasma. Q-switched (QS) lasers are effective for the management of epidermal pigmentation but are associated with a high risk of PIH. Long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and IPL sources pose less of a PIH risk but require a greater number of treatment sessions. Dermal pigmentary disorders are better targeted by QS ruby, QS alexandrite, and QS 1064-nm Nd:YAG lasers, but hyper- and hypopigmentation may occur. Non-ablative skin rejuvenation using a combination approach with different lasers and light sources in conjunction with cooling devices allows different skin chromophores to be targeted and optimal results to be achieved, even in skin of color. Deep-tissue heating using radiofrequency and infra-red light sources affects the deep dermis and achieves enhanced skin tightening, resulting in eyebrow elevation, rhytide reduction, and contouring of the lower face and jawline. For management of severe degrees of photoaging, fractional resurfacing is useful for wrinkle and pigment reduction, as well as acne scarring. Acne, which is common in Asians, can be treated with topical and oral antibacterials, hormonal treatments, and isotretinoin. Infra-red diode lasers used with a low-fluence, multiple-pass approach have also been shown to be effective with few complications. Fractional skin resurfacing is very useful for improving the appearance of acne scarring. Hypertrophic and keloid scarring, another common condition seen in Asians, can be treated with the combined used of intralesional triamcinolone and fluorouracil, followed by pulsed-dye laser. Esthetic enhancement procedures such as botulinum toxin type A and fillers are becoming increasingly popular. These are effective for rhytide improvement and facial or body contouring. We highlight the differences between Asian skin and other skin types and review conditions common in skin of color together with treatment strategies.

Recent advances in laser dermatology

Lasers have revolutionized the practice of modern dermatology. Our understanding of laser physics and selective photothermolysis has expanded greatly over the last 20 years. In the last 2 years, we have looked beyond the traditional lasers and explored new concepts. This article will look at five of these new concepts. A strong understanding of these new techniques will allow dermatologists to use them either primarily or in combination with more conventional methods.

Skin rejuvenation by radiofrequency therapy: methods, effects and risks

Treatment of sun-damaged skin and wrinkles is attracting increasing interest as the possible approaches expand. Recently mono- und bipolar radiofrequency devices have been introduced as new treatment options for skin rejuvenation. Initial studies have demonstrated changes in collagen content of the skin as the molecular basis of skin texture improvement. However, there are many possible risks and side effects. We describe a patient referred to us with severe facial scarring as a result of a bipolar radiofrequency treatment performed by non-medical personnel. Due to the risk of permanent tissue damage, the indications for radiofrequency interventions should be made carefully. Potential contraindications should be considered and written informed consent about all possible side effects and risk factors should be obtained. According to current knowledge, the experience of the physician using radiofrequency devices is most important in determining the outcome of this procedure. Therefore the use of radiofrequency therapy requires extensive training.

Technology approaches to the medical spa: art plus science equal rejuvenation

Medical spas are the fasting growing segment of the 15-billion dollar spa industry. Although medical spas have been in existence since ancient times to treat a wide variety of ailments such as gout, arthritis, and diabetes, our modern concept of the medical spa combines relaxation with medical rejuvenative procedures. This article focuses on the more recent technologic advancements in rejuvenation.

Laser surgery in dark skin

Although challenging, effective laser surgery in patients with darker skin tones can be achieved despite a higher inherent risk of side effects. Although the incidence of undesirable postoperative sequelae has decreased with the development of advanced laser technology and individualized treatment parameters, these risks may never be eliminated completely. Consequently, thorough patient preoperative preparation and education regarding the risks of cutaneous laser therapy will remain an essential component of treatment in darkly pigmented patients. In the future, as more refined laser techniques evolve, the ability to safely and effectively treat these patients will improve.

Latest laser and light-based advances for ethnic skin rejuvenation

BACKGROUND

Advances in nonablative skin rejuvenation technologies have sparked a renewed interest in the cosmetic treatment of aging skin. More options exist now than ever before to reverse cutaneous changes caused by long-term exposure to sunlight. Although Caucasian skin is more prone to ultraviolet light injury, ethnic skin (typically classified as types IV to VI) also exhibits characteristic photoaging changes. Widespread belief that inevitable or irreversible textural changes or dyspigmentation occurs following laser- or light-based treatments, has been challenged in recent years by new classes of devices capable of protecting the epidermis from injury during treatment.

OBJECTIVE

The purpose of this article is to review recent clinical advances in the treatment of photoaging changes in ethnic skin. This article provides a basis for the classification of current advances in nonablative management of ethnic skin.

Shrinking upper and lower eyelid skin with a novel radiofrequency tip

BACKGROUND

Many subjects wish to have tightening of eyelid skin but are reluctant to undergo aesthetic blepharoplasty surgery. We wanted to perform a small pilot study to test the efficacy and safety of a 0.25-cm(2) monopolar radiofrequency tip in a prospective noncomparative study as a novel nonsurgical method to safely tighten upper and lower eyelid skin in subjects of differing ethnicity and sex.

METHODS

Twenty adult subjects were enrolled in this prospective pilot study. All received symmetrical monopolar radiofrequency treatments in multiple passes to the pretarsal, preseptal, and lateral orbital skin. All subjects wore a protective plastic haptic contact lens to protect their vision during the radiofrequency treatment. (Haptic contact lenses fit over the entire anterior surface of the globe from superior to inferior and medial to lateral fornix. The purpose of using such a large contact lens was to protect the globe itself from radiofrequency energy.) Standardized color digital photography with eyes both open and closed was taken on each visit. Treatment efficacy was evaluated by both the expert observer and the subject at each visit. RESULTS At 6-month follow-up, according to the expert observer, 26 upper lids (87%) showed 25% or more tightening. Twenty lower lids (67%) showed 25% or more tightening. Two subjects (3.33%) had 51% to 75% upper lid tightening at 6 months. There were no adverse events beyond one subject with minimal corneal epithelial punctate defects on the treatment day. These resolved over several hours.

CONCLUSIONS

The use of this new tip was shown to be safe. Effectiveness at shrinking eyelid skin was at best mild to moderate.

Adverse reactions after nonablative radiofrequency: follow-up of 290 patients

BACKGROUND

Monopolar radiofrequency has been Food and Drug Administration approved for the noninvasive treatment of periorbital rhytides and wrinkles in 2002 and for full-face treatment in 2004. In order to establish the degree of side effects in our practice, a retrospective review was done.

OBSERVATIONS

Seven hundred fifty-seven treatments of nonablative monopolar radiofrequency were done on 290 patients. Two hundred sixty-four patients were women (91%), and 26 were men (9%). Two hundred fifty-nine of these patients were treated for facial lifts. Patients were treated with an average energy setting of 81 J/cm(2). Treatments were all done with a 1-cm(2) tip that gives a 2.3-s pulse, and 11.49% of treatments were particularly painful for the patient. The appearance of second-degree burns occurred in 2.7% of the treatment sessions. Other less frequent adverse reactions were persistent erythema (1.22%), headache, scarring, edema, fat atrophy, burn in the return pad site, neuralgia, and facial palsy. The occurrence of facial palsy might be a coincidence.

CONCLUSIONS

In comparison with other studies, we have found a very low incidence of posttreatment erythema and edema. On the other hand, the incidence of second-degree burns is somewhat higher. This might be due to the fact that in other studies higher energy settings have been used but without overlapping pulses. Monopolar radiofrequency is a safe method of treating the skin of the face and neck, and it should be done at moderated energy settings with no immediate overlapping in order to avoid overheating and undesirable side effects.