Bipolar and multipolar radiofrequency.

BACKGROUND: The increased demand for anti-aging treatments over the past decade has fueled the development of multimodality devices. This allows for more efficacious treatment of dermal defects, excess adiposity, and skin laxity. Radiofrequency (RF) devices are constantly evolving and consequently adding multiple indications for their use. In this article, the authors focus on bipolar and multipolar RF modalities. OBJECTIVE: The objective was to review, summarize, and evaluate the key studies of procedural therapies using bipolar and multipolar RF technologies. METHODS: Studies selected for evaluation had clear statements of purpose, patient selection, follow-up evaluations, previous and concurrent medications, treatment parameters, methods for evaluating results, and adverse effects. All studies were complete and published in peer-reviewed journals. RESULTS AND CONCLUSION: With their unique mechanism of action, bipolar and multipolar RF devices remain versatile treatment options associated with minimal downtime and pain compared with monopolar RF and other nonablative modalities. Proper patient selection and education along with an experienced treating physician is crucial in achieving patient satisfaction and results. It is important that larger studies are conducted to provide data on upcoming devices. Review of the literature provides a starting point for physicians seeking to treat patients safely and effectively with newer devices.

New tattoo approaches in dermatology.

Tattoos have fascinated mankind for centuries. Although these body marks were once considered to be permanent, technical and scientific progress in recent years has made it possible to remove tattoos by various treatment modalities. Contemporary technology involves the use of nonablative quality-switched lasers, which are considered to be the gold-standard treatment option for the removal of unwanted tattoo ink. Current research in the field of tattoo removal is focused on faster lasers and more effective targeting of tattoo pigment particles including picosecond laser devices, multi-pass treatments, dermal scatter reduction, application of imiquimod, and the use of microencapsulated tattoo ink.

Facial volume augmentation in 2014: overview of different filler options.

Volume loss is considered to be one of the major contributors to facial aging. Therefore, the restoration of facial volume and contour changes has become an important treatment approach in aesthetic dermatology in recent years. In October 2013 the FDA approved for the first time ever an injectable dermal filler for the augmentation of age-related volume loss. This low-molecular-weight (LMW) 20 mg/ml hyaluronic acid (HA) filler competes on the market with poly-L-lactic acid (PLLA) and calcium hydroxylapatite (CaHA), that have been used off-label for many years to restore age-related volume loss. The safety profile and efficacy of all three injectables has been intensively evaluated in innumerous clinical studies. However, each volume filler has its benefits and disadvantages, including usage, method of action and duration of effect that are reviewed in this article.

Histological and electron microscopic analysis of fractional micro-plasma radio-frequency technology effects.

OBJECTIVE: The aim of this explorative study was to investigate the histological effects of a novel micro-plasma radio-frequency technology for skin rejuvenation the assessment of different parameters. METHODS: Thirty guinea pigs were randomly selected and were distributed into three treatment groups: 40W/10KJ, 60W/10KJ, and 80W/10KJ. The treated skin was analyzed immediately, one week and one month post-treatment using histology and transmission electron microscope (TEM). RESULTS: At 40W/10KJ, the epidermis was intact and light collagen homogenization was observed in the papillary dermis. At 60W/10KJ, the epidermis showed focal emergence of fractional shape change and obvious papillary dermal homogenization. At 80W/10KJ, the epidermis was completely vaporized and the superficial and mid-dermal layers of collagen tissue showed a large area of homogenization. Dermal collagen increased in density and became arranged in an orderly manner after one week and markedly thickened and arranged in compact manner after one month. TEM showed that epidermal cells were relatively complete, intercellular structure was normal, but the dermal collagen lost its typical structure, cell structure disappeared and showed massive apoptosis. A low level of apoptosis marker expression was observed, with collagen structure restoration after one month. CONCLUSION: The treatment with the novel micro-plasma radio-frequency technique has a dose-dependent effect on the skin, especially on the dermal collagen tissue, where neocollagenesis is stimulated.

The history of aesthetic medicine and surgery.

The history of beauty is as old as mankind itself--throughout history people have tried to improve their attractiveness and to enhance their beauty. The technical basis for many of nowadays procedures like lipoplasty, breast augmentation or rhinoplasty was thereby initiated more than a hundred years ago and evolved to the modern standards of today. The aim of this article is to recall the early days of aesthetic medicine and show the swift progress up to the highly specialized medical discipline of our modern time. Combining the past, present and future of aesthetic medicine, allows to incorporate this perspective and ultimately to delivery better patient care.

Prospective multicenter clinical trial of a minimally invasive temperature-controlled bipolar fractional radiofrequency system for rhytid and laxity treatment.

BACKGROUND: A minimally invasive fractional bipolar radiofrequency (FRF) was developed. OBJECTIVE: To evaluate safety and efficacy of FRF in reducing face and neck rhytides and laxity. MATERIALS AND METHODS: This prospective, open-label, multicenter clinical trial enrolled 100 subjects with mild to severe facial and neck rhytides and laxity at seven centers in a per-protocol analysis. One single-pass FRF treatment was administered through five 32 g-needle electrode pairs at a preselected real-time fixed temperature of 62 to 78°C, energy duration for 3 to 5 seconds, and impedance restrictions of 200 to 3,000 Ohms, ensuring intradermal delivery. Five blinded dermatologists and plastic surgeons graded randomized standardized baseline and follow-up photographs of 53 and 42 subjects at 3- and 6-month follow-up intervals, respectively, using the Fitzpatrick wrinkle and Alexiades-Armenakas laxity scales. Subject assessments and adverse events were recorded in 100 subjects. RESULTS: Blinded evaluations revealed correct pre- and post-treatment identification in 100% of scored cases, mean improvement of 25.6% on the Fitzpatrick Wrinkle Scale and 24.1% on the Alexiades-Armenakas laxity scale at 6 months, and 100% response rate for rhytides and 95% for laxity. Subgroup analysis revealed maximal rhytid reduction in the mean target temperature of 66.7, energy duration of 4.2 seconds, and volume of denatured collagen of mm(3) denatured collagen group. Adverse events included transient erythema, edema, and ecchymoses, resolving within 1 to 5 days, and two incidents of temporary pinpoint depressions. More than 90% of subjects were satisfied or very satisfied. CONCLUSION: Real-time temperature-controlled FRF is a highly reproducible, safe, effective nonsurgical treatment of face and neck rhytides and laxity and provides important insights into neocollagenesis, neoelastogenesis, and clinical outcomes.

Safety of dermal fillers.

Facial wrinkles are the most visible morphological change of the aging process. Therefore, several rejuvenation methods have been developed to cure these unloved signs of the times, such as botulinum toxin, laser treatments as well as topical active ingredients. Recently, dermal fillers have become a popular means of addressing contour defects and soft-tissue augmentation. Although this aesthetic treatment is considered to be relatively safe, the use of injectable dermal fillers is a minimally-invasive treatment, and as with any medical procedure, there is a risk for unwanted side effects.

Fractional laser skin resurfacing.

Laser skin resurfacing (LSR) has evolved over the past 2 decades from traditional ablative to fractional nonablative and fractional ablative resurfacing. Traditional ablative LSR was highly effective in reducing rhytides, photoaging, and acne scarring but was associated with significant side effects and complications. In contrast, nonablative LSR was very safe but failed to deliver consistent clinical improvement. Fractional LSR has achieved the middle ground; it combined the efficacy of traditional LSR with the safety of nonablative modalities. The first fractional laser was a nonablative erbium-doped yttrium aluminum garnet (Er:YAG) laser that produced microscopic columns of thermal injury in the epidermis and upper dermis. Heralding an entirely new concept of laser energy delivery, it delivered the laser beam in microarrays. It resulted in microscopic columns of treated tissue and intervening areas of untreated skin, which yielded rapid reepithelialization. Fractional delivery was quickly applied to ablative wavelengths such as carbon dioxide, Er:YAG, and yttrium scandium gallium garnet (2,790 nm), providing more significant clinical outcomes. Adjustable laser parameters, including power, pitch, dwell time, and spot density, allowed for precise determination of percent surface area, affected penetration depth, and clinical recovery time and efficacy. Fractional LSR has been a significant advance to the laser field, striking the balance between safety and efficacy.

Fractional, nonablative Q-switched 1,064-nm neodymium YAG laser to rejuvenate photoaged skin: a pilot case series.

BACKGROUND: Scientific research in the field of energy-based and light-based procedures made it possible to develop a very new and innovative generation of lasers that combine the benefit of a nonablative and a fractional laser device, promising skin rejuvenation without harming the epidermis. With this pilot case series, we performed one of the first systematic reports evaluating efficacy and safety of the fractional, nonablative Q-switched 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser device in the treatment of rhytides of the face, neck, and chest. METHODS: Seven healthy female subjects (mean ± standard deviation age, 53.8 ± 10.0 years) with visible signs of facial and neck skin aging were treated with fractional, nonablative Q-switched 1,064-nm Nd:YAG laser device (Pixel QS Nd:YAG; Alma Lasers Ltd, Caesarea, Israel). Treated areas were the face, including the periorbital and perioral regions (particularly the upper lip), neck, and chest. Treatments consisted of 3 sessions at 2- to 4-week intervals. Follow-up was performed monthly following the final treatment. The Alexiades-Armenakas Comprehensive Grading Scale of Skin Aging was employed to assess efficacy. Pain ratings were recorded by 10-point visual assessment scoring. RESULTS: Employing the validated, quantitative grading scale for rhytides of the face and neck, a 0.29 grade improvement, or 11.3% improvement, over baseline grade was observed in the 7-subject cohort that completed follow-up following a mean of approximately 2 treatments at approximately 1-month follow-up. No pain and rapidly resolving minimal erythema were noted in all subjects during treatment. CONCLUSION: The results of this pilot case series suggest that the treatment with the fractional, nonablative Q-switched 1,064-nm Nd:YAG laser device significantly improves superficial rhytides. With its outstanding safety, it seems to be particularly suitable for the treatment of sensitive areas, such as the periorbital region, lips, neck, and chest. The Q-switched Nd:YAG laser is a facile, safe, and fast treatment for aesthetic skin rejuvenation.

Combination laser-assisted liposuction and minimally invasive skin tightening with temperature feedback for treatment of the submentum and neck.

BACKGROUND: There is need for better nonsurgical treatment of excessive neck fat and skin laxity. OBJECTIVE: To assess combination laser-assisted liposuction (LAL) and minimally invasive skin tightening (MIST) of the submentum and neck under direct temperature control. DESIGN: Randomized, prospective, three-arm study of single LAL-MIST treatment comparing 1,064, 1,319 nm, and blended 1,064 and 1,319 nm. METHODS: Twelve subjects were randomized to three arms. LAL was fiber administered into the adipose layer, followed by aspiration. MIST was laser fiber administered into the subdermal plane. Multiple passes were administered until uniform 45-48°C was attained in the targeted plane. Energy delivery totalled 5,000-7,000 J. Subjects were photographed at baseline and 1, 2, 3, 4, 5, and 6 months after treatment and assessed using a 4-point quantitative laxity grading scale and fat aspirate quantitation. RESULTS: Mean ± standard deviation baseline, follow-up, and difference in laxity grades and percentage improvement over baseline for the three study arms and total were 3.19 ± 0.38%, 1.88 ± 0.85%, 1.31 ± 0.55%, and 43.8 ± 18.5%, respectively, for 1,064 nm; 3.75 ± 0.29%, 2.38 ± 0.25%, 1.38 ± 0.25%, and 36.6 ± 5.9%, respectively, for 1,319 nm; 3.38 ± 0.48%, 2.13 ± 0.63%, 1.25 ± 0.29%, and 39.3 ± 12.9%, respectively, for 1,064/1,319 nm; and 3.44 ± 0.43%, 2.13 ± 0.61%, 1.31 ± 0.36%, and 39.4 ± 12.1%, respectively, total. Mean fat aspirate volumes were 6.13 ± 3.28 mL for 1,064 nm, 8.25 ± 2.50 mL for 1,319 nm, and 6.50 ± 5.74 mL for 1,064/1,319 nm. Clinical improvement was consistent across all subjects; all before-and-after photographs are presented (save a recognizable subject for privacy). No blistering, scarring, or dyspigmentation was observed. CONCLUSION: Combination temperature-controlled LAL-MIST treats excess fat and skin laxity of the submentum and neck with excellent safety and efficacy.

Aging facial skin: infrared broad band light technologies.

The application of infrared broadband light is the more recent addition of nonsurgical laser and light-based treatment for skin laxity and rhytids. Infrared broadband light, when used with the mobile technique, offers a painless, safe, nonsurgical alternative treatment option for treatment of skin laxity on the face and neck. Multiple clinical studies have demonstrated improvements in skin laxity correlated histologically with neocollagenesis and neoelastogenesis over a 6-12 month period. The consistency of clinical improvement in skin laxity supports the use of this approach for moderate skin laxity.

Multi-center clinical study and review of fractional ablative CO2 laser resurfacing for the treatment of rhytides, photoaging, scars and striae.

Laser skin resurfacing has shifted over the past two decades from standard ablative resurfacing to non-ablative resurfacing and most recently, to fractional laser resurfacing. In this most recent category, fractional non-ablative lasers were first introduced followed by fractional ablative lasers, which offer an improved balance between safety and efficacy. In the current article, a review of fractional ablative resurfacing is presented alongside the results from a multi-center clinical study employing the fractional carbon dioxide (CO2) laser (SmartXide DOT, DEKA) for the treatment of rhytides, photoaging, scars and striae distensae.

Blinded, randomized, quantitative grading comparison of minimally invasive, fractional radiofrequency and surgical face-lift to treat skin laxity.

OBJECTIVES: To quantify the improvements in laxity from the surgical face-lift and to perform a randomized, blinded comparison with the clinical effects of a novel, minimally invasive fractional radiofrequency (FRF) system. STUDY DESIGN: Randomized, blinded, comparative trial. PATIENTS: Fifteen sequential patients with facial skin laxity enrolled in the trial and completed FRF treatment and follow-up. Baseline and follow-up digital photographs of patients undergoing FRF were randomly mixed with 6 sets of baseline and follow-up images of patients undergoing surgical face-lift with equivalent baseline facial laxity grades. MAIN OUTCOME MEASURES: Five independent blinded evaluators graded randomized baseline and 3- to 6-month follow-up photographs using a comprehensive quantitative 4-point laxity grading scale. Quantitative changes in laxity grades were calculated and compared statistically for FRF treatment vs surgical face-lifts. Patient satisfaction and adverse events were also evaluated. RESULTS: Blinded grading of unmarked, randomized baseline and follow-up photographs of patients undergoing FRF treatment randomized with baseline and follow-up photographs of patients undergoing surgical face-lift demonstrated statistically significant improvement in facial laxity, with a mean grade improvement of 1.20 for patients in the surgical face-lift group and of 0.44 for FRF-treated patients on a 4-point laxity grading scale (P < .001). The improvements relative to baseline were 16% for FRF treatment compared with 49% for the surgical face-lift. The mean laxity improvement from a single FRF treatment was 37% that of the surgical face-lift. Patient satisfaction was high (dissatisfied, 0%; neutral, 7%; satisfied, 60%; and very satisfied, 33%). All participants in the FRF treatment group experienced transient erythema, mild edema, and mild to moderate purpura that resolved in 5 to 10 days, and they returned to normal activities within 24 hours. There were no adverse events or complications in the FRF group. All patients in the surgical face-lift group experienced scarring at surgical margins, erythema, edema, and ecchymosis, and they returned to normal activities on suture removal at 7 to 10 days. CONCLUSIONS: This randomized, blinded, quantitative assessment using a validated grading scale of skin laxity improvement from the gold standard treatment, the surgical face-lift, and comparative analysis to a novel, minimally invasive FRF treatment has demonstrated 49% improvement in skin laxity relative to baseline for the surgical face-lift, compared with 16% for FRF. The surgical face-lift resulted in a mean 1.20-grade improvement on the 4-point laxity grading scale. In comparison, a single, minimally invasive FRF treatment demonstrated a 0.44-laxity grade improvement, or 37% that of the surgical face-lift, without the adverse effects and complications of surgical procedures. This study provides a basis for quantifying cosmetic outcomes from novel treatments with comparative analysis to the gold standard. It also suggests that minimally invasive FRF treatment may provide an important nonsurgical option for the treatment of facial skin laxity.

Assessment of the mobile delivery of infrared light (1100-1800 nm) for the treatment of facial and neck skin laxity.

BACKGROUND: Previous studies have shown that although infrared light and radiofrequency delivered by stationary application is safe and effective for the treatment of rhytides, a mobile delivery of radiofrequency energy can render the treatment as painless. In addition, few studies have defined and assessed efficacy of these infrared treatments in treating laxity by quantitative grading. OBJECTIVE: This prospective study assesses the safety, efficacy, and pain profile of the application of infrared light with a mobile delivery method for the treatment of facial and neck skin laxity as assessed by a tested, quantitative grading scale. METHODS: In this study, 22 female subjects (aged 40-75 years; Caucasian and Asian ancestry) with a clinically observable excess of laxity (minimum grade 2 out of 4) on the face received 1 to 3 treatments with incoherent infrared (1100-1800 nm) light at 2-week to 4-week intervals. Each light pulse was administered in a mobile continuous fashion within a localized area measuring approximately 1 handpiece tip-width laterally and vertically. A series of 4 to 5 pulses were administered across small grid areas, followed by 6 to 8 passes to each grid area, totaling approximately 300 to 450 pulses per treatment. Each mobile pulse was delivered at fluences of 45 to 46 J/cm2 to the face, 45 J/cm2 to the mandible, and 44 J/cm2 to the neck. Clinical results were evaluated employing a comprehensive 4-point grading scale from photographs at baseline, and the 1-month and 3-month follow-up visits after the final treatment. Pain ratings were evaluated by visual analog scale (VAS) gradings and patient questionnaire immediately following treatment. RESULTS: All subjects completed and responded to treatment. The mean treatment number was 2.1 (+/- 0.9) and the mean follow-up interval was 1.9 (+/- 1) months. The quantitative evaluations demonstrated: a mean baseline laxity grade of 2.9 +/- 0.5 and mean posttreatment laxity grade of 2.5 +/- 0.6; and a mean difference in prelaxity grades versus postlaxity grades of 0.4 +/- 0.3 (95% CI; 0.2540-0.5415). The data demonstrated a statistically significant difference between before and after measurements (P<.0001) and a mean percent improvement in laxity grading scores of 14.1 +/- 11.3%. The treatment discomfort was rated as a mean of 0.7 (+/- 0.6) on a VAS grading scale (0 to 10). By patient questionnaire, sensation during the treatment was rated as painless by 100% of patients and rare (<5) transient moments of heat-related pain sensation were reported by 18% of patients. None of patients reported the procedure as painful or as sensing frequent (>5) or persistent heat-related pain sensation during the treatment. Other side effects included minimal erythema which resolved within 1 to 3 hours. No crusting, dyspigmentation, or scarring was observed. CONCLUSION: This prospective clinical study with quantitative grading of laxity and VAS pain scores demonstrated that mobile delivery of infrared light appears to be safe, clinically effective, and painless in reducing facial and neck laxity. The mobile infrared light delivery allowed for delivery of approximately 30% higher fluence dosages and increased passes to each pulse area. The clinically observable and quantified decreases in skin laxity following treatment were statistically significant.