Multicenter study of noninvasive radiofrequency for periorbital tissue tightening

Dose Response of Combination Photorejuvenation Using Intense Pulsed Light–Activated Photodynamic Therapy and Radiofrequency Energy

OBJECTIVE

To report the results of a dose-response study using a novel photorejuvenation regimen consisting of intense pulsed light-activated photodynamic therapy and radiofrequency energy in patients with Fitzpatrick skin types I through III.

METHODS

A combination intense pulsed light and radiofrequency device (Syneron Medical Ltd, Yokneam, Israel) was used in combination with the topical photosensitizer aminolevulinic acid (ALA) (Levulan Kerastick; DUSA Pharmaceuticals Inc, Wilmington, Mass). Duplicate titration trials were performed on the dorsal forearm skin of 3 patients with Fitzpatrick skin types I through III. Multiple treatments, with varying times of application of ALA (30 minutes and 1, 2, and 3 hours) and intense pulsed light fluence (24-30 J/cm(2)), were completed to determine a minimal erythema dose and a maximal tolerated dose based on epidermal reaction (erythema and crusting) and patient discomfort. Radiofrequency energy levels were constant in all treatment groups.

RESULTS

The ALA application time of 1 to 2 hours for all skin types and fluence levels of 26 to 28 and 24 to 26 J/cm(2) for Fitzpatrick skin types I/II and III, respectively, were determined to be the minimal erythema dose. The ALA application times of 2 to 3 hours and fluence levels of 28 to 30 and 26 to 28 J/cm(2) for skin types I/II and III, respectively, were determined to be the maximal tolerated dose and resulted in severe erythema and crusting. The presence of severe erythema and discomfort precluded longer ALA exposure and higher fluence levels. No epithelial breakdown was observed at any treatment levels.

CONCLUSION

The dose-response results defining the minimal erythema dose and the maximal tolerated dose of intense pulsed light-activated photodynamic therapy and radiofrequency energy have led to the development of 2 photorejuvenation protocols based on skin type and severity of photodamage.

Radiofrequency Treatment for Middle and Lower Face Laxity

OBJECTIVE

To compare the effectiveness of 1 and 2 radiofrequency (RF) treatments with the ThermaCool TC system (Thermage Inc, Hayward, Calif) on middle and lower face laxity.

METHODS

Twenty patients with mild to moderate laxity of the middle and lower face were randomly assigned to receive either a single RF treatment or 2 treatments spaced 1 month apart. Treatment energy levels were titrated to patient tolerance and ranged from 85 to 135 J/cm(2). Acute clinical response was recorded after each session. Standardized photographs were taken before treatment and at 1 and 4 months after the last treatment. Using a percentage scale, 4 blinded physicians experienced in dermatologic laser therapy independently rated improvement in nasolabial folds, marionette lines, jowls, laxity under the chin, and overall appearance. In addition, subjects completed quality-of-life surveys 1 and 4 months after treatment. Each patient paid the same fee for involvement in the study.

RESULTS

Eleven patients received a single RF treatment, and 9 patients underwent 2 treatments. All subjects experienced mild edema and mild to moderate erythema as an acute clinical response; no patients experienced burns, skin breakdown, or scarring. At 4-month follow-up, patients in the 2-treatment group received higher scores in all categories of photographic analysis; the difference in improvement in the nasolabial folds was statistically significant (P = .04). In self-assessment ratings, individuals receiving 2 treatments reported more improvement than subjects in the single-treatment group 4 months after treatment (P = .03). In both treatment groups, physician photographic assessment demonstrated continued improvement in all subsites between the 1-month and 4-month assessments (P<.05). Although the overall change noted by both patients and physicians was modest in most patients, 75% of subjects (n = 15) stated they would consider paying for additional treatments.

CONCLUSIONS

Two RF treatments yielded significantly better improvement than a single treatment in the nasolabial folds. Significant improvement in laxity after treatment was seen between the 1- and 4-month follow-up visits in both single- and 2-treatment groups. Although overall improvements were modest in both groups, patient satisfaction was relatively high.

Objective Changes in Brow Position, Superior Palpebral Crease, Peak Angle of the Eyebrow, and Jowl Surface Area after Volumetric Radiofrequency Treatments to Half of the Face

BACKGROUND

Radiofrequency application through a proprietary device has recently been used for facial tissue tightening. Uniform volumetric heating of the dermis is created by passage of electrical current, while protection of the epidermis is maintained by concurrent cryogen cooling.

OBJECTIVE

To objectively quantify the effectiveness of volumetric radiofrequency application on the face, we treated 10 patients on the left side of the face with radiofrequency and evaluated the changes in brow position, superior palpebral crease, angle of the eyebrow, and jowl surface area.

METHODS

Uniform treatments were applied at 134 J/cm(2) to the left side of the forehead and 1 cm past midline, at 115 J/cm(2) to the left side of temple and cheeks, and at 97 J/cm(2) to the left side of the jaw line and inferior postauricular surface. Patients were evaluated at monthly intervals up to 3 months with digital photography. Morphologic changes were evaluated with the "measuring tool" and "angle tool" of the Mirror Suite imaging system for aligned frontal-view photographs (for eyebrow position, superior palpebral crease elevation, and eyebrow angle changes) and the "outline tool" for aligned oblique-view photographs (for jowl surface area changes).

RESULTS

At the end of 3 months on the side that was treated, patients exhibited on average 4.3 mm of brow elevation and 1.9 mm of superior palpebral crease elevation along the midpupillary line and an average of 2.4 mm of brow elevation along the lateral canthal line. There was no significant improvement of brow elevation along the lateral canthal line on the contralateral side. The peak angle of the ipsilateral eyebrow became slightly more acute by an average of 4.5 degrees after treatments. Moreover, the jowls on the lower part of the face, displayed a mean decrease of 22.6% in surface area after treatments. The nontreated side displayed a lack of eyebrow angle and jowl surface area changes.

CONCLUSIONS

The application of radiofrequency to the face provides quantifiable changes. The brow along the midpupillary line is elevated to a greater degree than the lateral brow. This is consistent with acute angle changes seen in the eyebrow. Improvements in the lower part of the face with radiofrequency application can be quantified by demonstrating a decrease jowl surface. Moreover, these measurement techniques can be useful tools for evaluating other treatment parameters with radiofrequency application.

Improvement of neck and cheek laxity with a nonablative radiofrequency device: a lifting experience

OBJECTIVE

Laxity of cheek and neck skin is a common cosmetic complaint of patients as they age. Improvement of skin laxity can be difficult to achieve without invasive surgical lifting procedures. The object of this study was to evaluate the safety and efficacy of a novel nonablative radiofrequency device in the treatment of cheek and neck laxity.

METHODS

Fifty patients (skin phototypes I to IV) with mild-to-moderate cheek laxity (n=30) or neck laxity (n=20) received one treatment with a radiofrequency device (ThermaCool; Thermage Corp., Hayward, CA). Topical anesthetic cream was applied under occlusion for 60 minutes before treatment of the skin extending laterally and inferiorly from the nasolabial folds to the preauricular regions and mandibular ridge for treatment of the cheeks and from the mandible to mid neck for treatment of the neck. Clinical improvement of treatment areas was independently determined by three masked assessors' evaluations of comparative photographs at baseline, immediately after treatment, at 1 week, and at 1, 3, and 6 months after treatment using a quartile grading scale (0=less than 25%, 1=25% to 50%, 2=51% to 75%, 3=more than 75% improvement). Patient satisfaction surveys were also obtained at each follow-up visit.

RESULTS

Significant improvement in cheek and neck skin laxity was observed in the majority of patients. Patient satisfaction scores paralleled the clinical improvements observed. Side effects were mild and limited to transient erythema, edema, and rare dysesthesia. No scarring or pigmentary alteration was seen.

CONCLUSIONS

Noninvasive radiofrequency bulk dermal heating of skin can achieve safe and effective tissue tightening of the cheeks and neck. Although tightening continued to be evident 6 months after a single treatment, the longevity of clinical results has yet to be determined.

Fractional Photothermolysis: A New Concept for Cutaneous Remodeling Using Microscopic Patterns of Thermal Injury

BACKGROUND AND OBJECTIVES

We introduce and clinically examine a new concept of skin treatment called fractional photothermolysis (FP), achieved by applying an array of microscopic treatment zones (MTZ) of thermal injury to the skin.

STUDY DESIGN/MATERIALS AND METHODS

Two prototype devices emitting at 1.5 microm wavelength provided a pattern of micro-exposures with variable MTZ density. Effects of different MTZ densities were tested on the forearms of 15 subjects. Clinical effects and histology were assessed up to 3 months after exposure. Treatment of photoaged skin on the periorbital area in an additional 30 subjects receiving four treatments over a period of 2-3 weeks was also tested. Tissue shrinkage and clinical effects were assessed up to 3 months after treatment.

RESULTS

Pattern densities with spacing of 250 microm or more were well tolerated. Typical MTZ had a diameter of 100 microm and penetrated 300 microm into the skin. Reepithelialization was complete within 1 day. Clinical effects were assessed over a 3-month period. Histology at 3 months revealed enhanced undulating rete ridges and increased mucin deposition within the superficial dermis. Periorbital treatments were well tolerated with minimal erythema and edema. Linear shrinkage of 2.1% was measured 3 months after the last treatment. The wrinkle score improved 18% (P < 0.001) 3 months after the last treatment.

CONCLUSIONS

FP is a new concept for skin restoration treatment. Safety and efficacy were demonstrated with a prototype device. Further clinical studies are necessary to refine the optimum parameters and to explore further dermatological applications.