Non-ablative Radiofrequency
for Facial Rejuvenation
Célia Luiza Petersen Vitello Kalil, Clarissa Prieto Herman Reinehr,
and Celso Alberto Reis Esteves Jr.
Abstract
Over the last decades, non- or minimally inva-
sive skin rejuvenation techniques have shown
continuous and growing demand. Although
surgical procedures are the “gold standard”
for facial and body skin sagging treatment,
many patients choose procedures with lower
downtime, even if it means more subtle results,
because they don’t want to be away from their
work and social activities. In order to fulfill this
need, a range of non-ablative devices was
introduced, such as lasers, devices using light
sources – as intense pulsed light (IPL) – and
radiofrequency. This chapters discuss radio-
frequency, an extremely valuable therapeutic
for rejuvenation, as it allows patients to keep
realizing their activities and also provides “nat-
ural” results.
Keywords
Radiofrequency • Rejuvenation • Collagen •
Skin aging • Non-ablative devices • Skin laxity
C.L. Petersen Vitello Kalil (*)
Department of Dermatology, Santa Casa de Misericórdia
de Porto Alegre Hospital, Porto Alegre, Brazil
Brazilian Society of Dermatology, Porto Alegre, Brazil
e-mail: celia@celiakalil.com.br; clinica@celiakalil.com.br
C. Prieto Herman Reinehr • C.A.R. Esteves Jr.
Brazilian Society of Dermatology, Porto Alegre, Brazil
e-mail: cla.reinehr@gmail.com; celsoj@ig.com.br
# Springer International Publishing AG 2018
M.C.A. Issa, B. Tamura (eds.), Lasers, Lights and Other Technologies, Clinical Approaches and Procedures in
Cosmetic Dermatology 3, https://doi.org/10.1007/978-3-319-16799-2_27
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Radiofrequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Types of Radiofrequency Delivery
(Monopolar/Multipolar (Bipolar and Tripolar)/
Fractional) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Histopathological Changes . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Other Indications: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Benefits of the Procedure (Pros and Cons) . . . . . . 368
Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Monopolar RF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Multipolar RF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Fractional RF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Contraindication to Radio in the Eyelid Region . . . . 368
Pre-procedure Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Application Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Expected Results, Number of Sessions, and
Session Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Immediate Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Adverse Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Clinical Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Combined Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
361
362
Introduction
Over the last decades, non- or minimally invasive
skin rejuvenation techniques have shown contin-
uous and growing demand (Mulholland 2011).
Although surgical procedures are the “gold stan-
dard” for facial and body skin sagging treatment,
many patients choose procedures with lower
downtime, even if it means more subtle results,
because they don’t want to be away from their
work and social activities (Mulholland 2011;
Bogle and Dover 2009; Brightman et al. 2009;
DeHoratius and Dover 2007; Afrooz et al. 2014;
Elsaie 2009; Sadick et al. 2009). In order to fulfill
this need, a range of non-ablative devices was
introduced, such as lasers, devices using light
sources – as intense pulsed light (IPL) – and
radiofrequency (Mulholland 2011; Alexiades-
Armenakas et al. 2008).
The use of radiofrequency as a treatment of
periorbital rhytides and sagging was described in
2003 by Fitzpatrick et al. with more than 80% of
the treated patients showing improvement after a
monopolar radiofrequency session (Fitzpatrick
et al. 2003).
Further studies have evaluated its use in the
treatment of sagging neck skin, improvement of
lower third face contour, management of atrophic
acne scars, and treatment of body laxity and cel-
lulite (Brightman et al. 2009).
Radiofrequency
The devices used for laxity treatment work pro-
ducing heat in enough amount to warm up the
dermis (DeHoratius and Dover 2007; Hodgkinson
2009). Beyond radiofrequency, ultrasonic waves
and infrared radiation devices also act through
dermal heating (DeHoratius and Dover 2007).
Radiofrequency is a form of electromagnetic
energy in which electrons move in an electric field
and change its polarity up to six million times per
second. The alternating electric current generated
fluctuates between 3 kHz and 300 MHz (Bogle
and Dover 2009; Osório and Torezan 2009).
When trying to move into the tissue, the resistance
C.L. Petersen Vitello Kalil et al.
to the rotational movement of electrons generates
high-frequency oscillation in the water molecules
of the dermis (Goldberg et al. 2008). This energy
oscillation is eventually transformed into thermal
energy (Ohm’s law) (Mulholland 2011;
Hodgkinson 2009; Osório and Torezan 2009).
The resistance to the passage of electrons depends
on the tissue’s characteristics, such as its temper-
ature and the concentration of water (Abraham
and Mashkevich 2007).
The formula that represents the total energy
follows:
EnergyðJÞ ¼ I2  R  T
I = current
R = tissue impedance
T = time of application
The principle that guides the process is called
reverse thermal gradient: protective epidermal
cooling occurs and dermal heating as well (Gold-
berg 2004). The epidermal cooling is applied
before, during, and after the application of the
radiofrequency handpiece (Goldberg 2004). This
protection of the epidermis results in lower risk of
infection, scarring, and pigmentary changes when
compared to ablative procedures.
The heating of dermal collagen between 50 and
70  C (Celsius degrees) results in the rupture of
hydrogen bonds and in changes in the conforma-
tion of collagen fibers, which lose their three-
dimensional structure and assume an amorphous
form, causing it to contract by 30% and thickening
the fiber (immediate tissue retraction)
(Hodgkinson 2009; Bogle et al. 2007). The colla-
gen contraction is a time- and temperature-
dependent process, every 5 of temperature reduc-
tion, a 10 min increment is required to obtain the
same amount of retraction (the Arrhenius equa-
tion) (Brightman et al. 2009). In monopolar radio-
frequency, the dermis heating is expected to reach
around 65–75  C, and the epidermis must be
maintained at a temperature below 40  C. If der-
mal heat produced is suboptimal, it will not
improve sagging and rhytides. In the event of an
Non-ablative Radiofrequency for Facial Rejuvenation
HEAT
Collagen triple helix molecule
Fig. 1 Representation of the immediate effect of dermal heating on the collagen fibers
excessive heat production, atrophy, scars, ero-
sions, and skin discoloration may occur (Royo
de la Torre et al. 2011) (Fig. 1).
After that begins the subepidermal inflamma-
tory reaction process resulting in neocollagenesis
and a gradual improvement seen in 6–12 weeks
(late effect) (Steiner and Addor 2014).
Moreover, the heat delivered to the deeper
tissues stimulates adipose tissue capillary blood
flow and accelerates lipid metabolism (Hodgkinson
2009).
Types of Radiofrequency Delivery
(Monopolar/Multipolar (Bipolar
and Tripolar)/Fractional)
Monopolar Radiofrequency
First generation of radiofrequency. Volumetric
heating (three dimensional) of the dermis and
subcutaneous occurs in a short period of time.
Maximum depth reached is 20 mm, and it depends
on the size and geometry of the handpiece (Steiner
and Addor 2014). The type of handpiece used and
the amount of energy delivered through it are the
main determinants of depth reached (Hodgkinson
2009; Alster and Lupton 2007). Handpieces with
larger contact areas on the treated surface obtain
deepest dermal heating (Goldberg et al. 2008).
There is only one active electrode in contact
with the skin surface to be treated (dipole in the
device handpiece) in this type of radiofrequency,
and the current flows from this electrode toward a
neutral or return electrode placed in a distant
location, usually in the back (Hodgkinson 2009).
Most of the heat is produced in the area located
below the active electrode (Steiner and Addor
2014) (Fig. 2).
363
Collagen denatured fibers
Thermage CPT System (ThermaCool ®)
1. Radiofrequency generator: alternating current
(AC) 6.78 MHz, maximum flow 225 J/cm2,
with a display through which current, energy,
number of sections, duration of treatment, and
impedance can be monitored. At the display
the energy can be selected according to the area
to be treated (Hodgkinson 2009; Abraham and
Mashkevich 2007).
2. Pulsed cryogen within the treatment
handpiece: cooling system before, during, and
after the application of radiofrequency (Gold-
berg 2004).
3. Cable connected to disposable treatment
handpiece containing treatment electrode
inside: single use, with duration limited by
the number of shots (200, 400, or 600) and
time (“one handpiece, one patient, one treat-
ment”) (Hodgkinson 2009; Abraham and
Mashkevich 2007).
4. Microprocessor: located on the handpiece
which controls pressure, current flow, and
skin temperature in contact with the handpiece
(Abraham and Mashkevich 2007).
There are 0.25 cm2 handpieces used to treat
the upper eyelid and fine wrinkles and 3.0 cm2
handpieces used to lower eyelid, periorbital
wrinkles, and bottom of the eyebrow region. In
addition there is the DC handpiece body and a
specific body handpiece for cellulite treatment
(Hodgkinson 2009).
A complete cycle of radiofrequency emissions
ranges from 1.5 to 1.9 s (Steiner and Addor 2014).
The treatment is performed in the clinic with no
need of topical anesthetic since it is slightly painful
and also because heat intensity evaluation by the
364 C.L. Petersen Vitello Kalil et al.

Fig. 2 Representation of
affected depth of the tissue
by monopolar and bipolar
radiofrequencies,
respectively

Fig. 3 Patient 1 –
ThermaCool. One session –
treatment for contouring
and facial sagging
improvement (before and
after 8 months)

patient is necessary to reduce the risk of possible
complications. The postoperative does not require
specific care and one session gives good results
(Steiner and Addor 2014) (Figs. 3, 4, and 5).
Multipolar Radiofrequency
Bipolar
In this type of radiofrequency, there are two active
electrodes in contact with the area to be treated,
located at a fixed distance, and the current flows
only in the space between them (closed power
circuit) (Sadick 2007). This type of radio-
frequency shows a more superficial dermal
heating and reaches a maximum depth
of 2–4 mm, and this maximum depth is half the
distance between electrodes. More sessions are
necessary to achieve similar results to those
obtained with monopolar radiofrequency (Steiner
and Addor 2014). Among the RF devices that use
bipolar energy, we quote Aluma™/Lumenis ®,
Santa Clara, and Accent ® and Accent XT ®,
Alma Lasers.
Non-ablative Radiofrequency for Facial Rejuvenation 365

Fig. 4 Patient 2 –
ThermaCool. One session
for abdominal contour
improvement (before and
after)

Fig. 5 Patient 3 –
ThermaCool. One session,
0, 25 cm tip, eyelids and
periorbital treatment,
improvement of the side
and upper eyelid sagging

Tripolar power, approximately 50 W (Steiner and Addor

It is the third generation of radiofrequency, which
has three active electrodes that deliver energy and
enhance the flow. Although smaller, the energy
released is more concentrated when compared to
the mono- or bipolar radiofrequency (Steiner and
Addor 2014). This technique allows homoge-
neous heating of the dermis and hypodermis,
reaching 20 mm deep with the use of lower
2014). An example of this technology is found in
the device Apollo TriPollar ®, Pollogen LTDA.
Fractional Radiofrequency
Fractional radiofrequency consists of minimally
invasive technique of bipolar radiofrequency
wherein the heat generated by an electromagnetic
current results in cellular evaporation in the
366 C.L. Petersen Vitello Kalil et al.

epidermis (Reddy and Hantash 2009). Electro- collagen III occurs at a higher intensity than that of
magnetic waves cause oscillations of the water type I collagen, with a peak between the sixth and
molecules and produce thermal energy in the der- tenth weeks post procedure (Meshkinpour et al.
mis. This controlled volumetric heating of the 2005; Zelickson et al. 2004). Javate et al. demon-
dermis will finally stimulate the neocollagenesis. strated an intact epidermis with increased thick-
The device comprises electrodes or microneedles ness and amount of collagen fibers in the
arranged in pairs. The technique combines superficial and deep dermis post-radiofrequency
non-ablative coagulative effect on dermis with non-ablative biopsies (Javate et al. 2011).
areas of controlled ablation in less than 5% of In 2011, El-Domyati et al. observed that after
the treated epidermis (Taub and Garretson 2011). six biweekly interval monopolar radiofrequency
This RF mode allows intermediate areas of treated sessions, skin biopsies showed epidermal hyper-
skin with untreated areas that function as a cell plasia that continued to increase 3 months after the
reservoir and accelerate the healing. Fractional end of the treatment, increase of granulosa layer,
radiofrequency can be used in facial rejuvenation and increase in the epidermal organization degree.
and treatment of acne scars (Steiner and Addor Besides that, the study showed elastosis reduction
2014; Taub and Garretson 2011). in the papillary dermis and increase in the amount
of collagens I and III, 3 months after treatment that
Plasma were statistically relevant (El-Domyati et al. 2011).
Newest type of radiofrequency uses the state of Study with non-ablative lasers (Pulsed Dye
matter called plasma. Plasma pulses are created Laser and Nd:YAG) observed similar effects in
when very high radiofrequency energy passes stimulating collagen production and in the eleva-
through inert nitrogen and oxygen gas and gener- tion of crucial enzymes for dermal proteins
ates ionized gas. The handpiece directs this formed remodeling of the extracellular matrix (MMPs)
energy to the treated surface. The operating princi- (Orringer et al. 2005).
ple is the same as other types of radiofrequency
with dermal heating and stimulating neo- Table with the main radiofrequency non-ablative
devices
collagenesis (Rivera 2008; Spandau et al. 2014).
Radiofrequency devices/ Radiofrequency
manufacturer (RF) technology
Key features of the types of radiofrequency Thermage™/Thermage Monopolar RF
Multipolar Aluma™/Lumenis ®, Santa Bipolar RF and vacuum
Monopolar Bipolar Tripolar Clara
Accent ®, Accent ® Unipolar and bipolar RF
1 active 2 active electrodes 3 actives
XL/Alma Lasers
electrode electrodes
Apollo TriPollar ®/Pollogen Tripolar RF
Depth Depth 2–4 mm Up to 20 mm
LTDA
20 mm
Polaris ReFirme™/Syneron Bipolar RF and diode
Deeper More superficial, Deeper; energy is
laser
multiple passages, more concentrated
greater number of than monopolar ReFirme™/Syneron Bipolar RF and optical
sessions radiofrequency Medical energy
Reaction™/Viora Multipolar RF and
vacuum
PowerShape™/Eunsung Multipolar/bipolar RF
Histopathological Changes Global Corp. and vacuum
Apollo ®/Pollogen LTDA Bipolar RF
According to what was reported by Zelickson et al. Venus Freeze ®/Venus Multipolar RF
and Meshkinpour et al., denaturation of collagen Concept
fibers and mRNA expression of collagen I are Triniti E-max ®/Syneron Bipolar RF + diode laser
observed after the radiofrequency. The increase in Candela
Non-ablative Radiofrequency for Facial Rejuvenation 367

Table with the main radiofrequency ablative devices
Radiofrequency devices/
manufacturer
Scarlet RF™/Viol Co., LTDA
HF Fraxx ®/Loktal
Matrix RF ®/Syneron
Renesis ®/Primaeva Medical,
Inc.
ePrime ®/Syneron Candela
Duet RF PowerShape ®/
Eunsung Global Corp
and Torezan 2009; Site Thermage). Goldberg
Radiofrequency et al. evaluated the efficacy of monopolar radio-
(RF) technology frequency treatment of cellulite in the thigh in six
Fractional bipolar RF sessions with biweekly intervals in 30 patients
Fractional RF with showing a circumference reduction of the thighs
microneedles and improvement in cellulite degree, with no
Fractional bipolar RF changes in lipid metabolism (Goldberg et al.
Fractional bipolar RF 2008).
Fractional bipolar RF
Fractional and
thermal RF Patient Selection

The ideal patient for radiofrequency facial

Indications
As a result, in general, facial contour (jaw) and
sagging are improved.
The technique can be used in the treatment of
moderate submental shrinkage and sagging in the
neck region.
The middle third of the face may also benefit,
with attenuation of the nasolabial groove and
reduction of sagging of the treated area (Sukal
and Geronemus 2008).
Other Indications:
Treatment of body cellulite – associated with bipolar
radiofrequency vacuum (VelaShape® – Syneron Candela )
(Brightman et al. 2009)
Waist circumference reduction – bipolar radiofrequency
associated with vacuum (VelaShape ® – Syneron
Candela) (FDA approved in 2007) (Brightman et al.
2009)
Treatment of atrophic acne scars – all types of
radiofrequency may be used (monopolar, multipolar, and
fractionated) (Taub and Garretson 2011; Rivera 2008)
Body treatment: laxity in the upper limbs, abdomen, and
buttocks (Hodgkinson 2009) (FDA approved in
December 2005)
Treatment of active acne – report with Thermage ®
(Dierickx 2004)
Radiofrequency in drug delivery (Subramony 2013;
Gratieri et al. 2013)
The radiofrequency may be used as an adjunct
in the treatment of gynoid lipodystrophy (Osório
rejuvenation should be between 30 and 60
years old, presenting with mild to moderate
skin sagging and facial rhytides, and should
have realistic treatment expectations (Abraham
and Mashkevich 2007; Goldberg 2004). Pa-
tients who underwent face lift surgery who pre-
sent recurrent mild laxity 2–3 years after the
procedure are, in general, good candidates for
radiofrequency (Hodgkinson 2009; Abraham
and Mashkevich 2007).
Patients presenting sagging after weight loss
and abdominal sagging after pregnancy also ben-
efit for body radiofrequency.
The correct patient selection is a major deter-
minant of the response level to treatment (Suh
et al. 2013). Patients with advanced age, who are
obese, and with marked sagging will present mild
results (Abraham and Mashkevich 2007). How-
ever, explained the limitations, if the patient does
not wish to be submitted to more invasive pro-
cedures, radiofrequency is an interesting option
(Goldberg 2004).
The correct selection of patients is a major
determinant of the level of response to treatment
(Suh et al. 2013). Patients with advanced age,
obese, and with marked sagging will have
less satisfactory results (Abraham and
Mashkevich 2007). However, if the patient
does not wish to be subjected to more invasive
procedures and even after the limitations have
been explained still wants to be subjected to
radiofrequency, it is possible to do it (Goldberg
2004).
368
Benefits of the Procedure (Pros
and Cons)
If we compare radiofrequency, a non-ablative
technique, with ablative and surgical procedures,
the procedure allows faster recovery and lower
risk of complications. The results, however, are
more discrete (Goldberg 2004). Another benefit
regards the possibility to realize the procedure in
all skin types, since radiofrequency operating
mechanism differs from lasers and there is no
absorption or scattering by the tissue melanin
(Abraham and Mashkevich 2007). Moreover, it
can be used on hairy areas without risks, because
it does not damage the follicle.
Contraindications
Monopolar RF
Absolutes (Abraham and Mashkevich 2007)
Patients with cardiac pacemaker or defibrillator
Patients with other implantable electronic devices
Skin pathologies on the application area
Infection at the application site
Presence of permanent fillers in the area to be treated,
especially polymethyl methacrylate (PMMA)
Relatives
Smoking
Autoimmune disease
Previous radiotherapy at the application site
Pregnancy
Chronic use of corticosteroids or nonsteroidal
inflammatory
Other conditions that can impair healing
It is not recommended to use monopolar radio-
frequency on areas with metal plates or on tattoos
(Abraham and Mashkevich 2007).
Multipolar RF
Absolutes
Patients with cardiac pacemaker or defibrillator
Patients with other implantable electronic devices
(continued)
C.L. Petersen Vitello Kalil et al.
Skin pathologies on the application area
Infection at the application site
Presence of permanent fillers in the area to be treated,
especially polymethyl methacrylate (PMMA)
Inelastic scars
The use of photosensitizing medication
Systemic neoplasm
Venous thrombosis in use of anticoagulants
Fractional RF
Absolutes
Patients with cardiac pacemaker or defibrillator
Patients with other implantable electronic devices
Skin pathologies on the application area
Infection at the application site
Presence of permanent fillers in the area to be treated,
especially polymethyl methacrylate (PMMA)
Silicone prothesis in the area to be treated
Use of copper IUD (in the case of treatment in the
lower abdomen)
Dental abscess if applied in the area of the face
Active rosacea
Contraindication to Radio in the Eyelid
Region
Patients who underwent prior cornea surgery can’t
be submitted to radiofrequency in the eyelid
region because of the need to use intrapalpebral
protector that could injure the cornea (Steiner and
Addor 2014).
Pre-procedure Care
The pre-procedure standardized photographs
are essential. There are systems that allow,
in addition to the standardization of photo-
graphs, the examination of variations in pig-
mentation and in epidermal thickness and the
number and depth of rhytides, enabling the
assessment of therapeutic response (Suh et al.
2013).
Non-ablative Radiofrequency for Facial Rejuvenation
Application Techniques
For monopolar and multipolar radiofrequency,
the following precautions should always be
followed:
1. Fulfillment of consent form with the necessary
explanations, expected results, and side effects
and possible complications. The term should
be applied by a dermatologist and all the
patient’s questions must be clarified. Make
sure the patient does not have any of the
contraindications to the procedure.
2. Before the procedure, it is necessary to remove
all metals that are in contact with the patient’s
skin (jewelry, costume jewelry, watches).
3. Clean the area of the skin that the application of
radiofrequency will be held, remove makeup
and perform antisepsis of the skin with isopro-
pyl alcohol (Steiner and Addor 2014).
After, for monopolar radiofrequency, pro-
ceed to the following steps:
4. Position the dispersive plate on the back of the
patient.
5. Apply the temporary marking grid, accompa-
nying the individual handpiece, on the area to
be treated.
6. If the procedure is performed in the eyelid area,
it is essential to use intrapalpebral protector
that should be of plastic material to prevent
its heating. This measure seeks to protect the
eye globe from heat, from the electric field, and
from mechanical damage.
7. Apply generous amount of specific fluid to
monopolar radiofrequency, provided by the
equipment company, over the area to be treated
to occur correct docking of the handpiece on
the skin. The handpiece should remain
completely in contact with the skin at the time
of application (Steiner and Addor 2014).
After completing the steps above, treatment is
started. The equipment automatically calculates
the impedance of the patient (Hodgkinson 2009).
The energy levels are adjusted as the treated area
changes according to the tolerance of the patient
(Jacob and Kaminer 2008).
369
It is recommended that, when defining the area
to be treated, the area adjacent to the one pre-
senting sagging and loss of shape will also be
treated so as to assist in support of dermal process
(Jacob and Kaminer 2008).
Since its introduction, algorithms’ application
has been modified. Today are proposed treatment
protocols with lower energy and greater number
of passages, as opposed to what was initially
described (individual passages with high energy),
with better results (Bogle et al. 2007).
Current techniques allow less discomfort to the
patient and more meaningful and homogeneous
results (Sukal and Geronemus 2008).
By making the procedure without requiring
anesthesia there is the possibility tolerable of
interaction with the patient during the procedure
as to the degree of warming sense. This fact made
it possible to avoid overheating the epidermis and
its complications (Sasaki et al. 2007).
During the execution of the procedure, the
patient will refer feeling warmth in the treated area.
Ideal heat is the one reported by the patient as
“warm” and it is not intolerable (Hodgkinson 2009).
There are three techniques described for the
application of monopolar RF:
1. Two simple passages
2. A scaled passage
3. A superimposed passage: recommended use in
the Thermage CPT ® device (Thermage, Inc.,
Hayward, California)
In the technique described as two simple pas-
sages, a row of passages is realized following the
squares marked by the temporary grid, and then a
second passage is performed on the marked cir-
cles in a staggered grid manner, alternating rows
(Abraham and Mashkevich 2007). Following the
completion of two passages, we proceed to the
vectors’ application, which consists of additional
passages following the direction in which the
elevation of the skin is desired (lifting effect)
(Abraham and Mashkech 2007).
The technique with multiple passages (staking),
maintaining the tissue heated, shows more efficient
results, since the heating of the dermis diminishes
370
the tissue’s resistance to the electrical current pas-
sage (Hodgkinson 2009). In the multiple passage
technique, the energy required is reduced at each
subsequent passage at the same location. Further-
more, the technique allows freedom to the operator,
who can perform higher number of passages in areas
that are more lax than in less affected areas (Jacob
and Kaminer 2008).
The study of Dover et al. compared the single
passage technique with the multiple one in 5,700
patients. In the group undergoing single passage,
54% of patients had improvement in skin laxity
after 6 months. On the other hand, in the multiple
passage group, improvement was observed in
84% of patients, which also reported less pain
during the procedure and greater satisfaction
with the results (Dover and Zelickson 2007).
The number of shots ranges from 400 to
800 for facial treatment session and from 1,000
to 1,200 on body section. On the face, many
practitioners choose to perform one side and
then the other. A session is performed in about
1 h. One may proceed to treatment of the entire
surface or only a localized area, such as the man-
dibular region and the forehead (Jacob and
Kaminer 2008). The expected effects of the ses-
sion are erythema and immediate contraction of
the treated surface, being able to also have local
edema (Hodgkinson 2009).
The multipolar radiofrequency differs from
the monopolar for not having marking grid and
dispersive plate. Glycerin fluid is used on the
application area of the skin, and there are specific
handpieces for each region (the face, lower eyelid,
and body). It is important to use an external infra-
red thermometer to monitor the temperature of the
epidermis, which should not exceed 40  C, to
avoid burns (Steiner and Addor 2014).
Expected Results, Number of Sessions, observed, which is responsible for the “lifting”
and Session Intervals effect immediately observed. Mild erythema also
The result can take up to 6 months to be noticed,
since it is dependent of neocollagenesis and der-
mal remodeling, starting on average between 2
and 3 months (Abraham and Mashkevich 2007).
C.L. Petersen Vitello Kalil et al.
Some patients also referred improvement of skin
color and texture with smoothed scars (Abraham
and Mashkevich 2007). Moreover, the results are
highly variable, and even the application with
suitable technique, some patients with show better
results than others. The photographic record
pre- and post-standardized procedure is essen-
tial in the evaluation of these patients (Steiner
and Addor 2014).
In monopolar radiofrequency with one session,
the results are obtained depending on time
described above. In individual cases, two to
three sessions with 6–12-month intervals between
them are required.
In order to study the effect of subsequent sessions
of monopolar radiofrequency, the study of Suh et al.
evaluated eight patients who underwent monopolar
radiofrequency sessions with Thermage CPT® appa-
ratus for facial rejuvenation over a period of 7 years.
The patients had an average of four sessions, with
intervals between them ranging 4–45 months. Dur-
ing this period, there was no worsening in the
assessment by the Glogau scale in eight patients,
and seven patients reported satisfaction with treat-
ment outcomes. Randomized studies with larger
numbers of patients are needed to confirm the find-
ings (Suh et al. 2013).
Regarding multipolar RF, a larger number of
sessions, most often five to six sessions every
10–15 days, are required (Steiner and Addor 2014).
Therapeutic response is also dependent on the
area being treated. The middle and lower third of
the face respond faster than the neck because they
have higher amounts of subcutaneous fat (Bogle
et al. 2007).
Immediate Effects
Soon after the procedure, local edema can be
occurs and remains for a few minutes after the
procedure and resolves spontaneously (Abraham
and Mashkevich 2007). Erythema and mild swell-
ing the endpoints are expected immediately after
the procedure (Sadick 2007).
Non-ablative Radiofrequency for Facial Rejuvenation 371

FDA-approved uses for: Monopolar RF – ThermaCool Clinical Cases

System (Thermage, Inc., Hayward, California): (Abra-
ham and Mashkevich 2007) Picture 3: Patient 1 – ThermaCool. One session
Treatment of periorbital skin sagging (FDA approved – treatment for contouring and facial sagging
2002) improvement ((before and after 8 months)
Treatment of periorbital rhytides (FDA approved 2002)
Picture 4: Patient 2 – ThermaCool. One session
Treatment of perioral rhytides (FDA approved 2002)
for abdominal contour improvement (before
Treatment of facial rhytides (FDA approved 2004)
and after)
Treatment of generally rhytides (FDA approved 2005)
Picture 5: Patient 3 – ThermaCool. One session,
0, 25 cm tip, eyelids and periorbital treatment,
improvement of the side and upper eyelid sagging
Adverse Effects
Combined Treatments
Edema May persist for up to
Acneiform eruption 1 week Supplementation with other treatments such as
Linear surface crusts IPL, fillers, botulinum toxin, chemical peels, and
Hypersensitivity of the In general up to 2–3 weeks microdermabrasion is beneficial and should be
neck after the procedure individualized according to the needs
Moderate erythema of each patient (Abraham and Mashkevich 2007).
Burns overlying skin Bad-quality technique,
Some devices combine optical energy to elec-
high energy application
Nodosities in the cervical Disappear in 1–2 weeks
trical energy, in general the association of radio-
region (Site Thermage) frequency with laser (Laser Diode – Polaris WR
Irregularities of jaw and Monopolar system) or light source (LIP – Aurora ®, SR, Syn-
temporal contour radiofrequency, occur with eron) and allow the treatment of vascular injuries
(Hodgkinson 2009) older equipment and pigmented hair removal and treatment of
Mild to moderate pain During the procedure, rhytides’ addition and sagging (Lanigan 2008).
(Site Thermage) disappears shortly after
The combination of the two types of energy has
Temporary paresthesia Perineural edema in
sensitive nerves, a synergistic effect, allowing the use of lower
disappears in weeks doses of both, with less risk of adverse effects
(Abraham and (Sadick 2007). In combined systems, in which
Mashkevich 2007)
the optimal energy used is lower than that usually
According to the manufacturer ThermaCool required, there is the possibility of use in patients
System ® (Thermage, Inc., Hayward, Califor- with higher phototypes with less risk of adverse
nia), 99.8% of monopolar radiofrequency effects (Alster and Lupton 2007).
non-ablative procedures performed show no We also found in the market devices for treat-
adverse effects (Abraham and Mashkevich ment of gynoid lipodystrophy linking bipolar RF
2007). Mild erythema and edema generally dis- vacuum and ultrasound (Syneron Candela
appear in less than 24 h (Sukal and Geronemus VelaShape ®) (Brightman et al. 2009).
2008).
The day after the procedure, the patient can
resume the skin care, as well as treatments previ- Take Home Messages
ously used (Hodgkinson 2009).
Regarding the fractional RF, hypopigmentation – Radiofrequency is extremely valuable in the
can occur if the fluence used is too high and therapeutic arsenal for rejuvenation as it allows
also postinflammatory hyperpigmentation in pre- the patients to keep realizing their activities
disposed patients (Mulholland 2011). and also provides “natural” results.
372
– The correct knowledge of the technique and
the proper selection of patients are extremely
important to the treatment success, since it is
dependent on these variants for the best results.
– Radiofrequency can be combined to others
rejuvenation techniques with synergistic
effects.
Cross-References
▶ Intense Pulsed Light for Photorejuvenation
▶ Non-ablative Lasers for Photorejuvenation
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