International Journal of

Review Article
Dermatology and Venereology
OPEN

Radiofrequency in Facial Rejuvenation

Jia-Jie Lyu and Sheng-Xiu Liu∗
Department of Dermatology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China.

Abstract
Rhytides and striae are prominent clinical signs of skin aging. Photoaging, characterized by a thinning epidermis and a
decrease in collagens, is the main form of skin aging. Delaying the aging process is a concerning issue for
dermatologists. Radiofrequency (RF) is a non-ablative technology used for skin rejuvenation, body contouring, and
weight reduction. The selective electro-thermolysis stimulates collagen contraction and neocollagenesis. Compared
to traditional cosmetic treatment, it has the advantages of fewer side effects and short patient downtime. This review
aims to summarize the efficacy and safety of different RF devices and the limitations during RF treatments.
Combinations of RF and other cosmetic technologies are demonstrated. Results have been approving for the various
uses of RF, including skin laxity and wrinkles smoothening. However, many studies use subjective ways of evaluation.
Further studies are needed to determine the optimization of RF treatments for facial rejuvenation.
Keywords: radiofrequency, rejuvenation, skin tightening, noninvasive, aging skin

Introduction Food and Drug Administration subsequently approved

As the demand for delaying the aging process increases,
skin rejuvenation, especially nonablative cosmetic tech-
nology, has become a research hotspot because of its
minimal damage, few complications, and favorable
effects. Nonablative rejuvenation methods stimulate the
body’s capacity for regeneration and mainly include
radiofrequency (RF) therapy, intense pulsed light therapy,
neodymium-doped yttrium aluminum garnet laser thera-
py, and erbium yttrium aluminum garnet laser therapy,
among which, RF is applied widely in clinic.
RF radiation is part of the electromagnetic spectrum, with
electromagnetic waves in the range of 3 kHz–300 MHz.
RF therapy is a noninvasive technology used for skin
rejuvenation, body contouring, and weight reduction. The
electric current generated by RF electrodes flows to tissues
and produces thermal energy acting on the body. In 2002,
the US Food and Drug Administration approved the
ThermalCool monopolar RF device (Thermage, Hayward,
CA, USA) for smoothing periocular wrinkles.1 The US
∗ Corresponding author: Dr. Sheng-Xiu Liu, Department of Dermatology, The
First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China.
E-mail: liushxiu@126.com.
Conflicts of interest: The authors reported no conflicts of interest.
Copyright © 2022 Hospital for Skin Diseases (Institute of Dermatology), Chinese
Academy of Medical Sciences, and Chinese Medical Association, published by
Wolters Kluwer, Inc.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-
ND), where it is permissible to download and share the work provided it is
properly cited. The work cannot be changed in any way or used commercially
without permission from the journal.
International Journal of Dermatology and Venereology (2022) 5:2
Received: 6 April 2020, Revised: 23 October 2020, Accepted: 24 June 2021
doi: 10.1097/JD9.0000000000000193
RF therapy for treating facial skin in 2006. The applications
of RF therapy have since expanded to cosmetic treatment
of the cervical, abdominal, and femoral skin.2 With the
advantages of few adverse effects and short patient
downtime, RF therapy has gained increasing popularity
in facial rejuvenation during the last decade.
In this review, relevant English literature published from
2014 to 2020 was retrieved from the PubMed database. The
search terms “radiofrequency,” “RF,” “facial rejuvena-
tion,” and “skin tightening” were searched for relevant
clinical trials. This review summarizes the potential
mechanisms, applications, and types of RF devices currently
used in facial rejuvenation. The strengthens and limitations
of RF devices are also discussed.
Characteristics of aging skin
Aging of the skin includes intrinsic chronological aging
and extrinsic aging, which results in age-related loss of
function and esthetics. Photoaging results from prolonged
exposure to ultraviolet light and accounts for most aging
of the skin. Photoaging is histologically characterized by a
thinning epidermis, a decrease in collagen, deposition of
abnormal elastic fibers, and vessel ectasia.3 Inflammation
and apoptosis are regarded as hallmarks of photoaging. At
the molecular level, matrix metalloproteinases increase
during the aging process, promoting the degradation of
type I and type III collagen fibers in the extracellular
matrix.4
The gross appearance of aging skin can be described as
follows. Rhytides and striae are prominent clinical signs of
aging facial skin. Photodamage and facial expressions can
accelerate the formation of fine and coarse wrinkles on the

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Lyu and Liu, Int J Dermatol Venereol (2022) 5:2
frontal, periocular, and nasolabial areas. With advanced
age, increased accumulation of excess epidermal pigmen-
tation causes skin staining such as melasma and age spots.
Moreover, the appearance of skin laxity and weakness is a
frustrating problem following childbirth and bariatric
surgery. Permanent scar formation and post-inflammato-
ry hyperpigmentation (PIH) are secondary to other
dermatoses such as acne scars, which can similarly impair
facial esthetics. These skin changes make people look
much older than they are.
RF devices in facial rejuvenation
The general classification of commercially available RF
devices is based on the number of electrodes. The four
most commonly used techniques are monopolar, unipo-
lar, bipolar, and multipolar RF and are evaluated in this
review. Another application of RF devices is combining
them with other physical cosmetic treatment methods.
For instance, fractional RF with microneedling can
potentiate the penetration and treatment effect without
causing unnecessary injury to nearby tissues.5-6 The
combination of RF therapy and ultrasound contributes to
reduction of the soft layer. The development of these
combination therapies has significantly extended the
scope of RF applications. Each of the methods mentioned
above has unique advantages and applications in
cosmetic dermatology.
Monopolar RF therapy
Monopolar RF device was the first approved commercial-
ly available RF device for cosmetic purposes, and consists
of a generator and a handheld tip. Some of these devices
are designed with cooling systems to protect the epidermis
from the heating effect produced by RF energy. A
grounding pad filled with a conductive electrode paste
is placed on the patient’s body surface. An electric current
generated by the monopolar RF system is delivered
through the skin, into the body, and finally to the
grounding electrode.5 The dermis is then warmed from
65°Cto75°C, sparing the epidermis.2 The penetration
depth of monopolar RF is about 20 to 25 mm, which is
deeper than that of bipolar or unipolar RF. Monopolar RF
devices have been widely used for smoothing and skin
tightening, but adverse events such as pain and burning
during treatment tend to be more frequent because of the
deep penetration depth. Less frequent adverse reactions
are erythema, headache, scarring, edema, fat atrophy, and
facial palsy. Animal studies have revealed that inappro-
priately used monopolar RF energy may also induce ocular
effects, mainly cataracts. To avoid these adverse reactions, it
is necessary to cover the patient’s eyes and set a moderate RF
energy level with no immediate overlapping when perform-
ing facial monopolar RF treatment.7
A clinical study used monopolar RF device engineered
with great power and a self-monitoring circuit for
treatment of mid and lower facial rejuvenation with
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no reported significant adverse events. Each subject
underwent four serial treatments at 1-month intervals,
and increased collagen was observed at 3 months post-
treatment.8
A randomized double-blind study revealed that sub-
jects’ periorbital wrinkles improved after treatment with
the monopolar RF device Silk’n SHT (Home Skinova-
tions, Ltd., Richmond Hill, ON, Canada). The analyzed
data revealed a mean decrease of 1.49 in the Fitzpatrick
score and a significant reduction of rhytides (P < 0.001) in
almost all subjects with high satisfaction scores. Addi-
tionally, no correlation was found between skin type and
wrinkle improvement.9
In 2017, researchers used a 1-MHz monopolar RF
device (Cutera, Inc., Brisbane, CA, USA) to treat lower
facial tightening and fat reduction for 5 weeks. Most
patients reported high satisfaction scores for the skin
tightening effects, and the efficacy of the fat reduction was
maintained even at the 2-month follow-up. No obvious
complications occurred in this study.10
Unipolar RF therapy
A unipolar RF device has a single electrode and emits RF
energy in all directions without delivering an electric
current. These devices have no grounding pad in contact
with the patients’ body. The most marked difference
between a unipolar and monopolar RF device is in how
they deliver energy. The penetration depth of unipolar RF
ranges from 15 to 20 mm.2 Some manufacturers have
designed home-use RF devices using a unipolar handpiece,
which is safe, convenient, and compliant for users.
A double-blind randomized clinical study evaluated the
eyebrow-lifting effect of a home-based novel unipolar RF
device (DermaWand; ICTV Brands, Inc., Wayne, PA,
USA) in women. Fifty women aged 30–70 years were
randomized to receive the active device with 100 kHz or
the placebo device on each half of their face, and the
eyebrow-to-hairline distance decreased with no adverse
therapeutic effects after treatment. This study demon-
strated the safety and convenience of a household unipolar
RF device in upper facial skin tightening.11
A retrospective study was performed to evaluate the use
of a novel unipolar RF handpiece device referred to as
Tune Face, which is used skin tightening. After a 3-month
follow-up period at a 2-week interval, skin biopsies of the
subjects revealed improved skin laxity and an increase in
thick collagen bundles in the dermis without pain.12
Bipolar and multipolar RF therapy
With recent developments in RF technology, bipolar and
multipolar RF devices have been used in multiple fields. A
bipolar RF device comprises two electrodes without a
grounding plate. The patient’s skin is appropriately
positioned between the two electrodes, and a high-
frequency electrical current passes through the skin
precisely from a handpiece. The penetration depth of
Lyu and Liu, Int J Dermatol Venereol (2022) 5:2
bipolar RF is approximately one-half the distance between
the two parallel electrodes (about 2–8 mm).13 In contrast,
multipolar RF devices use three or more electrodes to deliver
thermal energy. One electrode is the positive pole, while the
remaining electrodes serve as negative poles. This feature of
multipolar RF devices prevents overheating and tissue
damage. Adverse events of bipolar RF therapy are limited to
mild erythema and swelling and usually resolve a few days
after treatment. PIH or hypopigmentation is rarely observed
during follow-up after bipolar RF treatment. The adverse
reactions of multipolar RF therapy are similar to those of
bipolar RF therapy. Both multipolar and bipolar RF therapy
remain excellent options associated with short downtime
and mild pain compared with other nonablative devices.
Because of the rapid onset and short fixed distance of the
action, some manufacturers have introduced a combination
of a bipolar RF device and other cosmetic technologies to
enhance the penetration and strengthen the effect. Combi-
nation approaches have several advantages. For example,
RF energy is set at the lowest level to minimize adverse
effects while preserving the desired efficacy. Additionally,
pain and burning sensation are less severe during vacuum-
assisted bipolar RF treatment. Moreover, RF devices with
distanced multiple electrodes can achieve specific skin
depths.
Nelson et al14 reported a case series in which 14 patients
were treated with a bipolar dermal heating device using an
RF handpiece (InMode Ltd., Irvine, CA, USA) for facial
skin tightening, and the patients reported no adverse
effects. According to the in vivo thermal view during the
initial application, the RF handpiece released energy and
treatment with a uniform heat distribution at 43°C. All
patients showed mild to significant improvement at their
follow-up visits.
Another study showed that percutaneous RF technology
could be used to simultaneously ablate the subcutaneous fat
and tighten the upper skin.15 In 2020, a multicenter trial
confirmed the ability and safety of a percutaneous bipolar
RF device (Serene Medical, Inc., Pleasanton, CA, USA) to
improve the appearance of glabellar lines. The reduction in
glabellar lines lasted for at least 3 months and was sustained
for about 1 year. The infrequent adverse events included
tenderness, swelling, bruising, and temporary paresthesia.
However, it was a nonrandomized clinical trial, and the
follow-up data were collected by telephone.16
A modified intramuscular insertion of a bipolar micro-
needling RF device (Candela Medical, Wayland, MA,
USA) was used to yield rejuvenated, tight skin with high
satisfaction scores in all patients. This device delivered
energy to the mimetic muscles; the local tissue temperature
reached 67°C, and the epidermal temperature was
maintained at 10°C. However, clinicians should be careful
about the angle of microneedles deployed.17
One study used a multipolar RF and pulsed electromag-
netic field synthesizer (Venus Freeze; Venus Concept,
Toronto, ON, Canada) to rejuvenate aged skin among
ten Korean patients who underwent eight treatment
sessions over 6 weeks. A high satisfaction score calculated
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using questionnaires was reported. This study confirmed
the efficacy and safety of the unique patterns of electro-
optical synergy devices in facial rejuvenation treatment for
East Asian patients.18
In another study, 30 patients underwent four multipo-
lar, multifrequency RF treatments (MIP-880, Mimari,
Inc., Poland) at 2-week intervals to improve their facial
skin texture and eliminate rhytides. The authors reported
a statistically significant improvement between measure-
ments taken before and 3 months after the treatment
without evident adverse effects.19
Fractional RF therapy
Minimally invasive fractional RF therapy delivers energy
directly to the dermis, leaving the epidermis slightly
injured. A fractional RF device exerts its effect through a
microneedle or electrode arrays. A fractional RF micro-
needle (FRM) device delivers the RF field using the
electrode array to identify the source of symptoms in
specific areas.20 This kind of RF energy has a maximum
penetration depth of 3.5 mm. Noninsulated and insulated
microneedles may be used in fractional RF devices. The
noninsulated microneedle serves as the electrode, while
the noninsulated microneedle device penetrates the
dermis. Maximum thermal coagulation injury areas can
be delivered to the targeted levels of the dermis except for
the active tip of the microneedle. Conversely, insulated
microneedle devices generate the energy flow through the
tip of the needle.21 Fractional RF therapy is considered a
relatively new method that is mainly applied to facial and
cervical rejuvenation. It can also enhance the percutane-
ous absorption of drugs and accelerate wound healing.
However, fractional RF devices have an increased risk of
treatment-related pain, temporary erythema, and mild
PIH. Nevertheless, the incidence of the most common
adverse effect of FRM devices is still significantly lower
than that of fractional laser treatment. A previous report
described a rare case of prolonged erythema and
inflammation lasting 18 months after FRM treatment.
The use of FRM treatment with high energy levels may
explain the infrequency of adverse reactions.22 To avoid
these effects, lower energy is applied in areas close to the
bone, such as the cheekbone, chin, and forehead.
A recent study involving Thai patients was performed to
evaluate the efficacy of fractional RF therapy (SVC, Viora,
Inc., New York, NY, USA) in facial skin tightening.23 This
study confirmed the reliability of RF treatment among
Asian patients with darker skin color.
Japanese researchers shared their clinical experience
with the use of the fractional bipolar RF device eMatrix
(Syneron Candela, Wayland, MA, USA) for improving
facial wrinkles and sagging. In this study, two programs
were designed and the differences between the two
programs indicated a 5% or 10% coverage rate of RF
energy. Each subject was treated every 4–6 weeks with a
peak energy of 25 J using a 200-mm-diameter pin.
Following treatment, obvious improvements were noted
Lyu and Liu, Int J Dermatol Venereol (2022) 5:2
in the lateral canthus and lower eyelids, and only mild
erythema was observed.24
A multicenter pilot study used fractionated RF with
insulated microneedles (INFINI; Lutronic, Inc., Billerica,
MA, USA) for lower facial rejuvenation treatment in a
three-pass procedure. The entire procedure lasted 30
minutes and comprised about 1000 pulses, and each
subject received a high RF energy of 11 J. Patient
downtime was reduced to 12–48 hours, and adverse
effects such as erythema or edema dissipated within a few
days.25
In Japan, a multisource phase-controlled RF device
(EndyMed Medical Ltd., Caesarea, Israel) that emits at
a 1-MHz frequency at 1–65 W for skin laxity was used
in a spilt-face study. After three rounds of treatment at a
1-week interval, the 3D images revealed notable improve-
ment on the treated side. Histological analysis revealed a
significant increase in the amount of elastin stain. Slight
improvements were also present on the untreated side of
the face.26
Combinations of RF therapy and other physical
technologies
To achieve synergistic efficacy, some researchers have
combined RF therapy with other physical cosmetic
technologies. Ultrasound generates areas of intense heat
and destroys the subcutaneous tissue. The penetration
depth of ultrasound is generally deeper than that of RF. In
some cases, the acting temperature is very high, such that
the treatment process increases the risk of facial nerve
injury. The combination of focused RF therapy and
ultrasound for facial rejuvenation results in high overall
patient satisfaction scores. In one study, the RF treatment
efficacy was assessed using clinical photographs by three
blinded physicians, and improved skin laxity was reported
at different body parts.27
Korean researchers have demonstrated a synergistic
effect of monopolar RF therapy and intense focused
ultrasound in a single rejuvenation treatment session. The
study recruited 22 women with a Fitzpatrick skin type of
3–4. A monopolar RF device called the Thermage CPT
System (Solta Medical, Inc., Raleigh, NC, USA) was used,
followed by application of the intense focused ultrasound
device to lift the skin off the full facial area for about 300
treatment lines per face. Following treatment and a 4-
month follow-up period, the assessed biopsy specimens
indicated increased and thickened interstitial fibers
throughout the dermis. The clinical assessment further
revealed that mild or improved skin laxity was observed in
95% of the patients.28
Multimodality treatment combined with bipolar RF
energy with optical energy, including intense pulsed light
therapy and infrared diode laser therapy, has remarkable
efficacy for improving erythema, telangiectasis, and skin
texture. Twenty-six patients aged 36–63 years underwent
four treatment sessions with an electro-optical synergy
device (Triniti; Syneron Medical Ltd., Yokneam, Israel)
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for full-face rejuvenation at 4-week intervals. Analysis of
the results was divided into objective and subjective
assessments. Following treatment and a 6-month follow-
up period, both the erythema index and transepidermal
water loss (TEWL) value had significantly decreased,
while the melanin index, stratum corneum moisture
scores, and dermis moisture scores had progressively
increased. These improvements were maintained for at
least 6 months, and the patient satisfaction rate reached
88%.29
A combination of the INFINI and fractional 1927-nm
thulium laser therapy has been used to eliminate loose
skin. After the third and fourth sessions, apparent
smoothing of wrinkles was seen in four middle-aged
patients. The patients received RF energy (7.5 W, 30-ms
exposure) followed by fractional 1927-nm thulium laser
energy (5 W, 10 mJ) with six to eight passes in total. At the
end of six treatment sessions and a 4-month follow-up
period, the efficacy and safety of this combination therapy
were confirmed.30
Mechanisms of RF therapy in rejuvenation
To achieve an optimal rejuvenation therapeutic effect, it is
essential to regulate collagen contraction and accurately
shrink the volume and number of adipocytes. The primary
mechanism of various RF methods is based on focused
tissue heating to stimulate collagen denaturation, remod-
eling, contraction, and regeneration.31 An RF device
transfers actively charged particles to target structures
through electromagnetic waves and forces particles to
collide for heat generation.6 The RF energy penetration
depth, which depends on the bioimpedance of tissues, RF
type, and initial RF energy settings, is related to the acting
temperature. Bioimpedance increases in the order of
water, nerves, muscles, collagen, and fat. The penetration
depth is inversely proportional to the frequency when the
impedance is fixed, meaning that RF therapy at lower
frequencies leads to deeper penetration.5
To permanently and noninvasively ameliorate wrinkles
and skin laxity, the most critical orientation is the deep
dermis and subcutaneous soft tissue layer. When RF energy
deposits, soft tissues may reach maximum contraction in the
interstitial space between two layers.32 Earlier monopolar
RF devices had poor controllability of energy in deep skin,
releasing energy on superficial skin to indirectly heat the
dermis and thus impairing the epidermis; the most
appropriate temperature for collagen contraction, there-
fore, could not be achieved. Application of RF devices in a
reverse trapezoid manner can help to heat deeper skin and
avoid epidermal ablation and denaturation of collagen
fibrils.13 Some adipocyte-selective devices are designed to
concentrate on the fat tissue layer, which enables the fat
tissue to heat up faster than other blood-rich tissue layers
such as the skin and muscle. This selective electro-
thermolysis keeps the local temperature at a relatively
low level and accurately heats the targeted layer without
damaging the surrounding structures.
Lyu and Liu, Int J Dermatol Venereol (2022) 5:2
Fibroblasts can produce more collagen at internal
temperatures above 42°C. RF thermal energy acting on the
skin leads to a series of changes: When they are within the
appropriate temperature range, collagen fibrils contract
immediately, although this contraction is only temporary
based on the breakage of the intramolecular hydrogen
bonds and the change in the helical structure. Histological
analysis reveals that RF thermal stimulation contributes to
short-term local microinflammatory stimulation of fibro-
blasts, and new collagen and elastin are produced in the
long term.33 The Exilis Elite (BTL Industries Inc., Boston,
MA, USA), a monopolar RF device mentioned earlier in
this review, was used on pigs’ abdominal areas once per
week for 4 weeks, and the collagen volume of skin samples
was calculated. The results indicated that the collagen
volume increased from 9.0% before therapy to 25.9% at
3 months after therapy. In this study, multi-pass and low-
energy monopolar RF treatment caused the most apparent
collagen contraction.33
The use of RF therapy for aging skin is effective in
inducing collagen regeneration. One of the underlying
mechanisms is encouragement of the expression of
transforming growth factor b,34 which can promote the
growth of dermal collagen and stimulate tissue repair.
Treatment with bipolar fraction RF led to up-regulation of
the Sirtuin gene family, which is involved in the regulation
of a variety of anti-aging processes and a decrease in the
expression of the apoptosis-related FoxO3 and p53
genes.35 RF thermal stimulation also enhanced adipocyte
metabolism and the degradation of adipose triglyceride
lipase. Induction of fat cell apoptosis may be another
mechanism.6
Applications of RF therapy in esthetics
The first use of RF therapy in the field of dermatology
was for improvement of skin photoaging. RF therapy
has since been used in facial rejuvenation, treatment of
uneven skin tone, face and body contouring, and
treatment of unsightly skin diseases. Additionally, RF
therapy manipulates the skin cooling system and can thus
serve as a beneficial esthetic tool for heating and reducing
fat tissue.
Upper face
Several new monopolar RF devices have been engineered
for combination with microneedles to protect tissues from
high levels of heat energy. A new RF device called AGNES
(Gowoonsesang Cosmetics Co., Ltd., Seoul, South Korea)
reportedly performs well in treating periorbital wrinkles.
One study revealed progressive positive changes in
periorbital wrinkles with use of the AGNES device, and
also showed that a monopolar RF device with a long
microneedle (1.5 mm) performed better than a short
microneedle (0.8 mm) in terms of decreasing the wrinkle
score.36 The portability and practicality of RF therapy in
the upper face areas have also been revealed. A study by
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Gold et al confirmed significant effects after RF
rejuvenation treatment in periorbital areas. Nobile
et al11 also reported a good curative effect in skin
tightening of the forehead after unipolar RF treatment.
Lower face and neck
A recent single-center retrospective comparative study
demonstrated that treatment with a fractional RF device
(Scarlet S; Viol Co., Ltd., Seongnam-si, South Korea) was
more effective for lower face areas than was treatment
with a fractional erbium yttrium aluminum garnet laser.
The assessments showed no significant change in
demographic data between the two treatment groups.
However, the reduction of wrinkles in the perioral,
nasolabial, and jawline areas was quite evident after
fractional RF treatment. Most patients expressed high
satisfaction with fractional RF therapy. Adverse effects,
including erythema, edema, and dryness, were not
apparent in the fractional RF group.21 The findings of
this study were consistent with the results obtained from
previous studies.
Jiang et al37 demonstrated improvements in moderate
lower facial wrinkles and laxity as measured by TEWL
after at least 5 months of fractional RF therapy (eMatrix;
Syneron Candela) and two follow-up periods. No
significant difference was found between TEWL at
baseline and after treatment. Nevertheless, the patients
reported improved skin texture and were satisfied with the
treatment. However, the sample size was limited to only
22 patients.
In a single-blind randomized controlled clinical trial,
researchers implied that lower facial wrinkles in adult
women showed no significant changes after fractional
bipolar RF therapy. One of the designed test groups was
based on the association between RF therapy with low-level
laser therapy; however, low-level laser therapy did not
enhance the effect of RF treatment.38 The negative results of
this trial were related to the very short duration of
treatment, and the long-term effect was not investigated.
The efficacy and safety of high-intensity focused RF
devices for lower facial and neck skin laxity were strongly
affirmed in another study.39 Although it was not a split-
face or comparative study, the results nonetheless deserve
consideration.
Limbs and trunk
A previous review highlighted the fact that RF devices can
be used to effectively reduce fat tissues, especially in the
abdomen and thighs.40 A non-contact RF device referred
to as enCurve1 (Lutronic, Inc.) was used to deliver an RF
field to selectively reduce abdominal fat and relatively
improve body contouring without affecting the epidermis
and dermis.41 An RF device at 27.12-MHz frequency was
reported to selectively and effectively reduce abdominal
fat in the epidermis, dermis, and adnexal structures of
pigs. The results showed a 70% decrease in the adipose
Lyu and Liu, Int J Dermatol Venereol (2022) 5:2
tissue layer with no impact on the serum levels of glucose,
urea, liver function, and other routine lipid markers after
four 30-minute treatments.42 Some researchers have also
shown that focused monopolar RF devices play an
important role in labial tissue tightening.43
Acne scars and other conditions
Other skin diseases can affect facial esthetics. Acne
vulgaris is commonly seen in adolescents and has heavy
psychosocial burdens. Notably, acne vulgaris often
continues to adulthood and causes permanent scar
formation. One type of acne scar is the atrophic scar,
which can be subdivided into icepick, rolling, and boxing
scars. Collagen remodeling induced by RF thermal
stimulation can soften rolling acne scars and icepick scars
with minor adverse effects.44 RF devices also facilitate
drug delivery in dyschromia, such as melasma and PIH.
The risk of hyperpigmentation is negligible after three
fractional RF treatments at a 3-week interval.45
Strengths and limitations
RF therapy has been successfully applied to improve skin
esthetics. Compared with conventional rejuvenation
methods, such as ablative laser therapy and surgery, RF
treatment has many benefits for skin rejuvenation, body
contouring, and weight reduction. RF therapy is a safe and
effective approach that improves facial rejuvenation in
patients of different ages worldwide. Because of its
“colorblind” property, RF treatment can be applied to
people with multiple skin colors or skin types. RF therapy
is not affected by the skin pigment content and hence does
not affect pigment formation after treatment. Important-
ly, RF therapy is a noninvasive or minimally invasive tool
that does not induce scar formation after treatment. Some
novel RF devices can directly heat the targeted tissue layer
without affecting the overlying skin, greatly minimizing
the incidence of adverse effects and complications.
Therefore, this technique significantly minimizes patient
downtime to only hours or several days. In previous
studies, the total treatment duration ranged from 1 week
to 6 months. The effects of RF treatment can last for a long
time. The emergence of home-use RF devices has made RF
treatment more convenient and practical. With the
exception of existing skin problems, RF therapy can
bolster the skin against future aging.
However, several limitations should be discussed.
Although positive outcomes of RF treatment have been
reported by many researchers, some studies did not
provide clear statistical evidence. Moreover, only a few
studies were randomized controlled trials. Some studies
drew conclusions based on physicians’ assessments and
patient satisfaction, which might not be adequately
objective. Moreover, several brands and models of RF
devices with different setting parameters exist on the
market, making their treatments nonuniform. For exam-
ple, the temperature, duration of heating action, and
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number of repeat operations in the same regions are based
on suggestions provided by manufacturers. Some adverse
effects of RF treatment have been reported, such as mild to
moderate pain during treatment, temporary edema,
erythema, and occurrence of PIH after treatment. Such
unwanted adverse effects can be minimized by applying
personalized RF energy to different facial areas and using
RF devices with a cooling system. Postoperative care
should be enhanced to reduce the rate of adverse reactions.
There are few persistent and severe adverse effects of RF
therapy. Extending the follow-up time in further studies
may allow for further elucidation of the long-term efficacy
and safety of RF. Another limitation is that topical
anesthetics are needed when using some types of RF
devices, such as micro-needling fractional RF devices.
Therefore, standardized preoperative and postoperative
analgesia regimens should be developed.
Conclusion
To improve skin rejuvenation, it is essential to develop
individualized and rational treatment strategies among
numerous cosmetic treatment options. The most promi-
nent feature of RF therapy is selective electrothermolysis.
Therefore, RF devices can accurately heat specific layers of
tissues, resulting in collagen contraction and skin
tightening. There are several advantages of RF devices
in treating facial skin laxity, wrinkles, and striae. RF
treatment has long-lasting effects, few adverse effects, and
short patient downtime, especially when compared with
traditional invasive treatments. However, therapeutic
standards and operation specifications of RF therapy
have not been unified. Therefore, more extensive
controlled experimental evidence needs to be established
to further explore the utility of RF therapy. RF therapy is a
safe and efficient facial rejuvenation method that deserves
to be studied for broader application.
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