M i c ro n e e d l e

R a d i o f req u e n c y
Macrene Alexiades, MD, PhDa,b,*

KEYWORDS
 Microneedle  Radiofrequency  Skin laxity

KEY POINTS
 Patient demand for nonsurgical alternatives to targeting skin laxity and rhytids have given rise to the
advent of microneedle radiofrequency (RF), which provides direct in situ delivery, impedance mea-
surements, temperature measurements, energy delivery controls, and targeting of various skin
depths to achieve desired clinical outcomes.
 Microneedle RF is a breakthrough that controls penetration depth and delivery to specified temper-
atures and impedance measurements, which ensure significantly improved efficacy in the treat-
ment of mild-to-moderate rhytids and skin laxity of the face, neck, and cellulite and laxity on
other body sites.
 Combining microneedle RF with dermal fillers and neuromodulators may be used to further improve
clinical outcomes and achieve high patient satisfaction.

BACKGROUND CANDIDATE SELECTION

More than any other laser-based or energy-based
technology, radiofrequency (RF) devices are the
most used for the treatment of skin laxity. Skin
laxity, manifested as sagging of the skin, is one
of the primary findings in skin aging (Table 1). Ac-
cording to the survey by the American Society for
Dermatologic Surgery, 67% of the population
request treatment for sagging skin on the jawline
and neck.1 Although the gold standard for the
treatment of facial and neck laxity is surgical rhyti-
dectomy, there is high patient demand for nonsur-
gical alternatives that eliminate the need for
systemic anesthesia, postsurgical morbidity, and
the fear of altered cosmetic appearance. Nonsur-
gical skin-tightening technologies such as RF do
not replace surgery for those with advanced to se-
vere skin laxity, but key advances such as micro-
needle delivery provide clinically meaningful
outcomes for those with mild-to-moderate skin
laxity on the face and with cellulite or rhytids on
The ideal candidate for microneedle RF is one with
mild-to-moderate skin laxity of the facial or neck
skin or with cellulite or rhytids on the body. Chief
complaints of patients with skin laxity include sag-
ging, crepey, or loose skin on the face or neck, and
deepening facial creases, jowls, lines, or folding on
face and/or body. Patients with cellulite complain
of linear undulations, dimples, or irregularity on
the buttocks or thighs.
DIAGNOSIS
A validated skin aging classification and grading
scheme is presented with a verified scale for rhyti-
des, laxity, and the subcategories of photoaging,
including dyspigmentation, erythema/telangiecta-
sia, solar elastosis, keratosis, and textural
changes (see Table 1).5,6 The clinical signs of
skin laxity of the face include nasolabial folds,
melolabial folds, jowls, submental and subman-
facialplastic.theclinics.com

the body, with minimal recovery and rare risk of dibular redundancy, and neck platysmal strands.
side effects or complications.2–4 Loss of elasticity and recoil are clinical findings.

a
Yale University School of Medicine, New Haven, CT, USA; b University of Athens Sygros Hospital,
Athens, Greece
* Dermatology and Laser Surgery Center of New York, 955 Park Avenue, New York, NY 10028.
E-mail address: email@nyderm.org

Facial Plast Surg Clin N Am 28 (2020) 9–15

https://doi.org/10.1016/j.fsc.2019.09.013
1064-7406/20/Ó 2019 Elsevier Inc. All rights reserved.
 10
Table 1
Quantitative comprehensive grading scale of rhytides, laxity, and photoaging

Alexiades Classification and Grading Scale of Skin Aging

Descriptive Erythema-
Grade Parameter Rhytides Laxity Elastosis Dyschromia Telangiectasia (E-T) Keratoses Texture
0 None None None None None None None None
1 Mild Wrinkles in motion, Localized to nasolabial Early, minimal yellowFew (1–3) discrete Pink E or few T, Few Subtle
few, superficial (nl) folds hue small (<5 mm) localized to irregularity
lentigines single site
1.5 Mild Wrinkles in motion, Localized, nl and early Yellow hue or early, Several (3–6) Pink E or several T, Several Mild irregularity
multiple, superficial melolabial (ml) folds localized periorbital discrete small localized to in few areas
(po) elastotic beads lentigines 2 sites
(eb)
2 Moderate Wrinkles at rest, few, Localized, nl/ml folds, Yellow hue, localized Multiple (7–10) Red E or multiple T, Multiple, Rough in few
localized, superficial early jowls, early po eb small lentigines localized to small localized sites
submental/ 2 sites
submandibular (sm)
2.5 Moderate Wrinkles at rest, Localized, prominent Yellow hue, po and Multiple small Red E or multiple T, Multiple, Rough in several
multiple, localized, nl/ml folds, jowls malar eb and few large localized to large localized
superficial and sm lentigines 3 sites areas
3 Advanced Wrinkles at rest, Prominent nl/ml folds, Yellow hue, eb Many (10–20) Violaceous E or Many Rough in
multiple, forehead, jowls and sm involving po, malar, small and large many T, multiple multiple
periorbital and Early neck strands and other sites lentigines sites localized sites
perioral sites,
superficial
3.5 Advanced Wrinkles at rest, Deep nl/ml folds, Deep yellow hue, Numerous (>20) or Violaceous E, Little Mostly rough,
multiple, prominent jowls and extensive eb with multiple large numerous T, uninvolved little
generalized, sm, prominent neck little uninvolved lentigines with little uninvolved skin uninvolved
superficial; few, strands skin little uninvolved skin skin
deep skin
4 Severe Wrinkles throughout, Marked nl/ml folds, Deep yellow hue, eb Numerous Deep, violaceous E, No uninvolved Rough
numerous, jowls and sm, neck throughout, lentigines, numerous T skin throughout
extensively redundancy and comedones extensive, no throughout
distributed, deep strands uninvolved skin

This 4-point grading scale has been extensively tested and used for evaluating laser-based and energy-based cosmetic treatments.
Data from Refs.2–6

Although body skin laxity lacks a validated
grading scale, the relative firmness of body skin
has been assessed by the presence or absence
of surface irregularities.2–6 Skin laxity on the
body similarly presents with rhytids, lack of recoil,
folds upon flexion, linear undulations, and poor
texture. Cellulite grading scales have been variably
tested and used.4
PATHOGENESIS
The dermal matrix of connective tissue confers the
properties of elasticity, recoil, and tensile strength.
The properties of elasticity and resilience are
attributed to the elastic fiber system, which con-
fers the deformability and passive recoil of tissue.
Collagen fibers provide tensile strength while hyal-
uronic acid provides turgor and skin moisture. In
diseases characterized by alterations in elastic fi-
bers, the skin is loose and sagging with a loss of
recoil, elasticity, and resilience.6–10 Elastic fiber
mutations, deficiency, degradation, or alteration
result in reduced skin elasticity and increased
skin laxity, which may be reversed through stimu-
lation of neoelastogenesis.6–10 By contrast, loss of
collagen is more closely associated with rhytid for-
mation. During the aging process, collagen and
elastin synthesis decrease, and elastin fibers are
degraded through sun exposure starting in the
third decade of life.
Heat denaturation of collagen and dermal
structures has been shown to induce histologic
dermal remodeling and clinical laxity reduction.11
In work by the author, it was discovered that
collagen greater than 70 C, which results in fully
denatured collagen, is associated with poorer
clinical outcomes; in contrast, intradermal tem-
peratures of 62 C to 67 C, which are associated
with partially denatured collagen, result in supe-
rior clinical efficacy in rhytid and laxity reduction.
The author has thus theorized that heat-induced
partially denatured collagens reveal RGD
sequences that via a signaling cascade result in
induction of neocollagenesis and neoelastogen-
esis.11 The neocollagenesis process has been
demonstrated to take up to 12 months following
treatment and correlates with progressive clinical
improvement.
MECHANISM OF ACTION
RF delivery to the skin creates thermal, mechani-
cal, and biochemical effects that induce dermal
remodeling. The increases in collagen, elastin,
and hyaluronic acid increase volume and improve
the elastic properties of the skin.12,13 RF
delivers controlled thermal injury that induces
Microneedle Radiofrequency 11
neocollagenesis and neoelastogenesis, which
correlate with clinical rhytid and laxity reduction.
RF is in the 3-kHz to 24-GHz frequency range
and, when delivered as an oscillating electrical
current, it induces collisions between charged
atoms and molecules in tissue, generating
heat.14 The penetration depth of RF is inversely
proportional to frequency; lower RF frequencies
penetrate more deeply when applied to the skin
surface. Heat is generated from the resistance of
tissue components to the movement of charged
and polar molecules within the oscillating RF field.
This resistance, termed impedance, generates
heat relative to the amount of current and time,
converting electrical current to thermal energy.
SUBTYPES
RF devices may be classified as noninvasive and
minimally invasive, the latter being delivered by
microneedles or probes. RF may be classified ac-
cording to electrode configuration: monopolar RF
uses a single electrode and a grounding pad; uni-
polar RF is via antenna transmission; bipolar and
tripolar RF use multiple electrodes in the hand-
piece tip whereby the current traverses the skin
via a closed circuit. The penetration depth of multi-
polar RF when delivered on the skin surface is
approximately one-half the distance between the
electrodes. Microneedle RF delivery bypasses
these barriers and delivers energy directly into
the dermis and subcutis. The singular break-
through of the first microneedle RF device (Pro-
found; Candela Medical, Wayland, MA) is that it
uses thermistors in the electrode needle tips,
allowing real-time feedback of both impedance
and temperature.2–4,13
The penetration depth depends on delivery
mode (skin surface, needle-based, or probe-
based), electrode configuration (monopolar or
multipolar), tissue type (skin, fat), and the fre-
quency of the current. Structures with higher con-
ductivity and impedance generate more heat: fat,
bone, and dry skin have low conductivities such
that current flows around rather than through
these structures; hydrated skin possesses high
electrical conductivity via the effects of water
dipole moment, thus allowing greater penetration
of current. Improved results are observed with
coupling fluid.
Monopolar Radiofrequency
Clinical study results from monopolar RF treat-
ment were first reported in 2003 by the author’s
group for the jowls and neck, and by Fitzpatrick
and colleagues for the periorbital area.14,15 The
original single-pass, high-energy method was later
12 Alexiades

compared with the low-energy, multiple-pass Unipolar Radiofrequency

technique demonstrating response rates of 54%
In 2008, the author invented the mobile delivery
and 92%, respectively, at 6 months. Anesthesia
method with a combined unipolar/bipolar RF de-
is no longer required and adverse events were
vice.20 Mobile delivery was used to increase flu-
also reduced to less than 0.05% with the modified
ence delivery to dermis while allowing cooling of
protocol.11 The device does not provide real-time
the epidermis. Mild efficacy in skin tightening
temperature feedback, so reliance on patient ver-
was observed in a split-face controlled trial
bal feedback regarding heat pain is still required.
comparing the unipolar with the bipolar RF hand-
An alternative skin surface applied monopolar
piece. Skin surface temperature profiles of 40 C
RF device operating at a frequency of 1 and
to 43 C were required, but efficacy was limited.
2 MHz, electrode sizes of 16, 25, and 40 cm2,
The same group reported efficacy in skin tight-
and providing skin surface temperature feedback
ening on the body using a similar mobile
was developed to treat skin laxity (truSculpt;
protocol.21
Cutera, Brisbane, CA). The author determined
that skin surface temperatures of 42 C to 46 C
are necessary to attain tissue tightening. Whereas Bipolar Radiofrequency
the 1-MHz and 16-cm2 tip is used for skin laxity, Skin surface bipolar radiofrequency
the recent 2-MHz (truSculpt 3D; Cutera) large Many skin surface–applied bipolar RF skin-
handpieces target skin laxity and fat reduction, tightening devices have been developed that
with approximately 25% circumferential reduction combine light energy or vacuum (Galaxy, Aurora,
in more than 90% of patients.16 Polaris, ReFirme, Sublime, and Vela III systems:
Another skin surface–applied monopolar RF de- Syneron Candela, Wayland, MA; Aluma: Lumenis).
vice (Pelleve; Ellman, Oceanside, NY) operates at RF current flows between the electrodes in the
4 MHz with handpiece tip sizes from 7.5 to handpiece tip via a closed loop through the skin
20 mm2. Fifty percent skin laxity and textural but is limited with respect to penetration depth.
improvement was reported at 1 year following 6 Arcing and burns may occur when inadequate
treatments.17 coupling gel is applied and the handpiece makes
incomplete contact with the skin. Modest efficacy
Probe-delivered monopolar radiofrequency has been demonstrated in clinical studies with skin
Monopolar RF may be delivered via a probe to the surface RF.22–26
subdermal plane for skin tightening of the jawline
and neck (ThermiTight; ThermiAesthetics, Irving, Needle-delivered bipolar radiofrequency Over the
TX). A blunt 10-cm, 18-gauge percutaneous treat- course of the last decade, the author and others
ment probe is inserted subdermally; the distal end have pioneered needle-delivered bipolar RF (Pro-
administers the current and contains a tempera- found; Syneron Candela). The first device to
ture sensor that initiates an automatic feedback deliver RF via a microneedle electrode array
loop to maintain subdermal tissue temperature directly into the reticular dermis, bypassing the
set at 50 C to 60 C. Subdermal temperatures of epidermis and papillary dermis, provided the first
65 C and 50 C were found to correlate with skin in situ real-time impedance and temperature feed-
surface temperatures of 41.6 C and 41.1 C, back using thermistors in the electrode tips
respectively.18,19 (Fig. 1). This device has undergone repeated im-
provements over the years in needle configuration,
Microneedle-delivered monopolar
radiofrequency
A variation on monopolar RF may be delivered via
uninsulated microneedle electrodes that are
grounded to the pad in the handpiece tip to create
a closed loop (VoluDerm, Pollogen; Lumenis,
Santa Clara, CA). The RF current is delivered via
a tip composed of an array of 36 microneedles
that penetrate the treated area as the needle tem-
perature increases, resulting in a treatment that
does not require topical or local anesthesia. The
full-length heating of the needles results in heat-
ing of both dermal and epidermal layers while
superficially penetrating the dermis (M.A., in
preparation). Fig. 1. Microneedle RF handpiece configuration.

gauge, manufacturing, and refinements in the pro-
tocol to optimize clinical outcomes. Single-use
treatment cartridges deliver 5 pairs of indepen-
dently controlled, 32-gauge, bipolar 250-mm
microneedles spaced 1.25 mm apart; each needle
pair is independently sensed and powered by the
RF generator. The proximal 3 mm of the 6-mm
needle is insulated to protect the superficial
portion of the skin during treatment while the distal
3-mm length is exposed to allow electrical current
flow between needle pairs to generate 3-dimen-
sional zones of thermal effects in the target. The
dermal handpiece is at a 25 angle so that the
tips of the needles are at a 2-mm depth from the
epidermis. As current flows between each needle
pair, fractionated zones (one between each pair)
of thermal injury are situated in the dermis 2 mm
from the surface of the skin. Epidermal cooling is
achieved via an integrated thermokinetic cooling
bar on the applicator. Intradermal targeting is
ensured by impedance measurements in the nee-
dle tips and software, ensuring firing within a spec-
ified impedance range. A target temperature is
selected by the user and energy is delivered until
the target temperature is attained and energy
titrated to maintain precise target temperature for
a selected pulse duration. The subcutaneous
handpiece delivers bipolar RF pulses using 5 pairs
of microneedle electrodes deployed into the
dermis at an angle of 75 with the exposed portion
extending from 3.9 to 5.8 mm beneath the skin
surface (Profound Sub-Q; Syneron Candela).
Zones of thermal injury with real-time temperature
monitoring using temperature sensors in each
electrode tip maintain a preselected target tem-
perature regardless of varying skin conditions
and improve consistency between patients.
The author’s group compared baseline and 3- to
6-month follow-up photographs of 15 patients
who underwent skin tightening using a micronee-
dle RF device with those of 6 patients who had un-
dergone rhytidectomy.2 The RF-device patients
were judged to have a 16% improvement from
Fig. 2. Microneedle RF clinical outcomes showing 2 sets of before (A) and after (B) photographs following a sin-
gle microneedle RF treatment (Profound, Candela).
Microneedle Radiofrequency 13
baseline and the surgical patients were judged to
have a 49% improvement from baseline laxity
grades, or a 0.46 versus 1.20 laxity grade reduc-
tion, respectively. The laxity grade reduction result
from a single microneedle RF treatment was 37%
that of a surgical facelift.2 In the subsequent multi-
center clinical trial and multiarm studies of target
dermal temperatures ranging from 52 C to 78 C,
the author and colleagues discovered that temper-
ature of 67 C in their cohort resulted in maximal
neocollagenesis, neoelastogenesis, and hyaluron-
ic acid production, and correlated clinically with
maximal rhytid and laxity reduction and a 100%
response rate.3 Higher and lower target tempera-
tures demonstrated less efficacy. The findings us-
ing needle-delivered RF support the theory that
partially denatured collagen is more effective at
triggering a strong wound-healing response.3
Fig. 2 shows 2 sets of “before” and “after” photo-
graphs following a single microneedle RF treat-
ment (Profound, Candela). Arrows indicate
findings of laxity at baseline including jowls and
submental laxity at baseline, and significant reduc-
tion of jowls and submental laxity with restoration
of mandibular definition on follow-up after a single
treatment. Similar skin-tightening effects were
observed on body skin laxity when the subcutane-
ous handpiece was used to treat cellulite.4 When
treating with microneedle RF on the body skin, a
reduction in linear undulations and textural irregu-
larities was observed.
Numerous needle-delivered bipolar RF devices
have been developed. One device allows for
adjustable needle depths to 0.5, 1.0, 1.5, 2.0
and 3.5 mm (Infini; Lutronic, Billerica, MA). The
device offers a 49-needle tip (10 mm  10 mm,
7  7 needles) and a 16-needle tip
(5 mm  5 mm, 4  4 needles). The microneedles
are surgical stainless-steel gold-coated for con-
ductivity and then double coated with an insu-
lating silicon compound, except for the distal
300-mm tip. The needles have a diameter of
200 mm and point diameter of 20 mm. The
14 Alexiades
insulation restricts the active area of the micro-
needle electrodes to the tip, and there is no elec-
trothermal damage delivered to the epidermis.
Clinical trials have demonstrated wrinkle reduc-
tion following treatment with this device, with
clinician-assessed overall efficacy and patient
satisfaction index similar at from 80.7% to
88.9% and 81.3% to 85.9%.27 Although the sys-
tem lacks real-time temperature feedback, a
recent improvement has incorporated imped-
ance measurements (Genius, Lutronic).
Another bipolar microneedle RF device (Inten-
sif; EndyMed Medical, Caesarea, Israel) includes
25 noninsulated gold-plated microneedle elec-
trodes 300 mm in diameter at the base, gradually
tapering to a sharp edge.28 Penetration depth of
up to 3.5 mm may be administered at 0.1-mm
digitally controlled increments. Maximal power
is 25 W with a maximal pulse duration of 200 -
milliseconds. The electrical impedance differ-
ence between the epidermis (high) and the
dermis (low) ensures RF flow through the dermis.
The RF emission delivered throughout the
length of the needle results in effective coagula-
tion with minimal or no bleeding, and dermal
heating.28
Another microneedle bipolar RF device (Frac-
tora; Invasix, Lake Forest, CA) administers
1 MHz to RF-conducting needles, alternating
current with 2 long side electrodes. The hand-
piece cartridges come as 600-mm or 3000-mm
long needles, which are 200  300 mm wide at
the base, for mid-dermal and deep dermal or
subdermal delivery, respectively.29 The mid-
dermal delivers 60 microneedles while the full
dermal or deep dermal/subdermal handpiece
contains 24 uncoated or coated needles, respec-
tively. The handpiece is loaded to the Fractora
platform (also applicable to InMode or BodyTite
platforms; Invasix/InMode MD, Israel). The de-
vice has been reported to result in significant
improvement in acne and acne scars.29
SUMMARY
Patient demand for nonsurgical alternatives to tar-
geting skin laxity and rhytids have given rise to the
advent of microneedle RF, which provides direct in
situ delivery, impedance measurements, tempera-
ture measurements, energy delivery controls, and
targeting of various skin depths to achieve desired
clinical outcomes. Microneedle RF is a break-
through that controls penetration depth and deliv-
ery to specified temperatures and impedance
measurements, which ensure significantly
improved efficacy in the treatment of mild-to-
moderate rhytids and skin laxity of the face and
neck, and cellulite and laxity on other body sites.
Although surgical face lifting remains the gold
standard, microneedle RF provides a clinically
meaningful alternative for those who wish to avoid
surgery or who have a milder condition.
Combining microneedle RF with dermal fillers
and neuromodulators may be used to further
improve clinical outcomes and achieve high pa-
tient satisfaction.
DISCLOSURE
Dr. Alexiades serves on the Medical Advisory
Board of Candela and has received research
grants from Candela, Cutera, Allergan, and
Biofrontera.
REFERENCES
1. American Society for Dermatologic Surgery (ASDS)
2015 Consumer Survey on cosmetic dermatologic
procedures. Data were collected from 7,315 con-
sumers through a blind online survey in spring
2015. Available at: https://www.asds.net/Portals/0/
PDF/consumer-survey-2015-infographic.pdf.
2. Alexiades-Armenakas M, Rosenberg D, Renton B,
et al. Blinded, randomized quantitative grading
comparison of minimally-invasive fractional radiofre-
quency and surgical facelift for the treatment of skin
laxity. Arch Dermatol 2010;146(4):396–405.
3. Alexiades-Armenakas M, Sarnoff D, Gotkin R, et al.
Multi-center clinical study and review of fractional
ablative co2 laser resurfacing for the treatment of
rhytides, photoaging, scars and striae. J Drugs Der-
matol 2011;10(4):352–62.
4. Alexiades M, Munavalli G, Goldberg D, et al. Pro-
spective multicenter clinical trial of a temperature-
controlled subcutaneous microneedle fractional
bipolar RF system for the treatment of cellulite. Der-
matol Surg 2018;44(10):1262–71.
5. Alexiades-Armenakas M. A quantitative and
comprehensive grading scale for rhytides, laxity
and photoaging. J Drugs Dermatol 2006;5(8):808–9.
6. Alexiades-Armenakas MR, Dover JS, Arndt KA. The
spectrum of laser skin resurfacing: non-ablative,
fractional and ablative laser resurfacing. J Am
Acad Dermatol 2008;58(5):719–37 [quiz: 738–40].
7. El-Domyati M, Attia S, Saleh F, et al. Intrinsic aging
vs. photoaging: a comparative histopathological,
immunohistochemical, and ultrastructural study of
skin. Exp Dermatol 2002;11:398–405.
8. Kielty CM, Sherratt MJ, Shuttleworth CA. Elastic fi-
bres. J Cell Sci 2002;115:2817–28.
9. Lewis KG, Bercovitch L, Dill SW, et al. Acquired dis-
orders of elastic tissue: part I. Increased elastic tis-
sue and solar elastotic syndromes. J Am Acad
Dermatol 2004;51:1–21.

10. Lewis KG, Bercovitch L, Dill SW, et al. Acquired dis-
orders of elastic tissue: part II. decreased elastic tis-
sue. J Am Acad Dermatol 2004;51:165–85.
11. Alexiades M, Berube D. Randomized, blinded,
3-arm clinical trial assessing optimal temperature
and duration for treatment with minimally invasive
fractional RF. Dermatol Surg 2015;41(5):623–32.
12. Alexiades-Armenakas M. Aging facial skin: infrared
broad band light technologies. Facial Plast Surg
Clin North Am 2011;19(2):361–70.
13. Willey A, Kilmer S, Newman J, et al. Elastometry and
clinical results after bipolar radiofrequency treat-
ment of skin. Dermatol Surg 2010;36(6):877–84.
14. Jacobson LG, Alexiades-Armenakas MR,
Bernstein L, et al. Treatment of nasolabial folds
and jowls with a non-invasive RF device. Arch Der-
matol 2003;139(10):1313–20.
15. Fitzpatrick R, Geronemus R, Goldberg D, et al. Multi-
center study of noninvasive RF for periorbital tissue
tightening. Lasers Surg Med 2003;33:232–42.
16. Sugawara J, Kou S, Kokubo K, et al. Application for
lower facial fat reduction and tightening by static
type monopolar 1-MHz radio frequency for body
contouring. Lasers Surg Med 2017;49(8):750–5.
17. Taub AF, Tucker RD, Palange A. Facial tightening
with an advanced 4-MHz monopolar RF device.
J Drugs Dermatol 2012;11(11):1288–94.
18. Key DJ. Integration of thermal imaging with subsur-
face RF thermistor heating for the purpose of skin
tightening and contour improvement: a retrospective
review of clinical efficacy. J Drugs Dermatol 2014;
13(12):1485–9.
19. Friedman DJ, Gilead LT. The use of hybrid RF device
for the treatment of rhytides and lax skin. Dermatol
Surg 2007;33:543–55.
20. Alexiades-Armenakas MR, Dover JS, Arndt KA. Uni-
polar vs. bipolar RF treatment of rhytides and laxity
using a mobile painless delivery method. Lasers
Surg Med 2008;40(7):446–53.
Microneedle Radiofrequency 15
21. Alexiades-Armenakas MR, Dover JS, Arndt KA.
Unipolar RF treatment to improve the appearance
of cellulite. J Cosmet Laser Ther 2008;10(3):
148–53.
22. Doshi SN, Alster TS. Combined diode laser and RF
energy for rhytides and skin laxity: investigation of
a novel device. J Cosmet Laser Ther 2005;7:11–5.
23. Sadick NS, Alexiades-Armenakas M, Bitter P Jr,
et al. Enhanced full-face skin rejuvenation using syn-
chronous intense pulsed optical and conducted bi-
polar RF energy (ELOS): introducing selective
radiophotothermolysis. J Eur Acad Dermatol Vene-
reol 2005;4:181–6.
24. Alexiades-Armenakas M. Rhytides, laxity, and pho-
toaging treated with a combination of RF, diode
laser, and pulsed light and assessed with a compre-
hensive grading scale. J Drugs Dermatol 2006;5(8):
731–8.
25. Yu CS, Yeung CK, Shek SY, et al. Combined infrared
light and bipolar RF for skin tightening in Asians. La-
sers Surg Med 2007;39(6):471–5.
26. Gold MH, Goldman MP, Rao J, et al. Treatment of
wrinkles and elastosis using vacuum-assisted bipo-
lar RF heating of the dermis. Dermatol Surg 2007;33:
300–9.
27. Calderhead RG, Goo BL, Lauro F, et al. The clinical
efficacy and safety of microneedling fractional RF in
the treatment of facial wrinkles: a multicenter study
with the infini system in 499 patients 2013. white
paper. Available at: us.aesthetic.lutronic.com.
28. Gold M, Taylor M, Rothaus K, et al. Non-insulated
smooth motion, micro-needles RF. Lasers Surg
Med 2016;48(8):727–33.
29. Dayan E, Chia C, Burns AJ, Theodorou S. Adjust-
able depth fractional radiofrequency combined
with bipolar radiofrequency: a minimally invasive
combination treatment for skin laxity. Aesthet Surg
J 2019;39(Supplement_3):S112–9.