Robert A. Weiss MD, Margaret A. Weiss MD, Girish Munavalli MD MHS, Karen L. Beasley MD
Background and Objectives: Monopolar radiofrequency skin heating coupled with cryogen cooling of facial skin for skin
tightening has been utilized on over 10,000 patients since 2002. In order to establish the actual rate and degree of side effects
in our clinical experience, a retrospective chart review was performed.
Study Design: Charts and clinical images of over 600 consecutive patient treatments between May 2002 and June 2006 using
a monopolar radiofrequency device (Thermacool®, Thermage, Haywood, CA) for skin tightening at the Maryland Laser, Skin
and Vein Institute were retrospectively reviewed. The primary presentation for treatment was skin laxity of the lower face.
Treatment was delivered with a 1-cm2 standard tip at fluences of 81 to 124 J/cm2 (level of 12.5 to 15), a 1-cm2 “fast” tip at
fluences of 62 to 109 J/cm2 (level of 72.0 to 76.0), a 1.5-cm2 “big fast” tip at fluences of 75 to 130 J/cm2 (level of 61.5 to 65),
and a 3-cm2 “bigger” tip at equivalent fluences as each became available. As treatment algorithms evolved over 4 years,
the algorithm of multiple passes at lower fluence associated with better clinical outcomes and greater patient acceptance has
Results: The most common immediate and expected clinical effects were erythema and edema lasting less than 24 hours,
although 6 patients reported edema lasting for up to 1 week. There were no permanent side effects. In total, 2.7% of treatments resulted in temporary side effects, the most significant of which was slight depression on the cheedk (n=1), which papules (n = 4) and a linear superficial crust (n=1) with the original tip, all of which resolved within 1 week. One patient reported small erythematous subcutaneous nodules resolving in 17 days. Tenderness of the neck lasting form 2 weeks (n=2) to 3 weeks (n=1) was also reported.
Conclusions: Our data, obtained in an office setting without injectable anesthetic or IV sedation, indicate that monopolar RF for skin tightening is ver safe procedure. The treatment algorithm and tips have evolved over several years leading to increased safety and efficacy. Side effects are infrequent, self-limited, and minor, comparing favorably to other nonablative devices utilized for facial rejuvenation.
Ramón H. Rosado MD, Ma. Emilia del Pino MD, Alejandro Azuela MD, Ma. Graciela Guzmán MD,
Background: Regardless of diet and exercise, genetics plays an important part in creating puckering skin or dimples, which
are difficult to hide at any age. The demand for a nonsurgical, noninvasive treatment of cellulite has inspired some
manufacturers to invest in a new age of sophisticated devices and treatment therapies to repair the skin and
improve contours. Although many of these new choices have demonstrated a smoothing effect (following a multitude of
treatments), the objective documentation has in most cases been limited to biopsies, circumference measurements, and
Hypothesis: We believe that the application of noninvasive high-energy radiofrequency (RF) to the skin of the thigh and
buttocks heats the subcutaneous adipose tissue, causing collagen fibers to contract. The resulting impact to the subcutaneous
tissue and collagen is expected to improve the skin’s external architecture. Given that the subcutaneous tissue and adipose
tissue are difficult to evaluate through histological methods, this investigation seeks to demonstrate the changes that occur
when applying 2 treatments of high-energy RF on the subcutaneous tissue of thighs and buttocks utilizing real-time
ultrasound image scanning.
Materials and Methods: Twenty-six healthy female patients (ages 18 to 50) with visible bilateral cellulite (grade 1 to 3) on
either the buttocks and/or thighs received 2 treatment sessions (15 days apart) of unipolar RF using the Accent RF System
(Alma Lasers Inc). The system utilizes a unipolar RF applicator that is electrically cooled to aid in patient comfort during
the treatment. Appropriate energy was set and the treatment was delivered in 3 passes of 30 seconds each. Evaluation of the
thickness of the subcutaneous tissue on buttocks and thighs took place before the first treatment, second treatment, and
15 days following the second treatment with a with real-time scanning image ultrasound (Philips Medical Systems). Clinical
improvement was objectively evaluated through comparative pre- and post-treatment measurements of the distance between
the stratum corneum to the Camper’s fascia and from the stratum corneum to the muscle. The study also evaluated the
structure and changes of the collagen (thickening and realignment of septae) resulting from 2 treatments of RF. Photography
was used to document contour and superficial changes.
Results: From the measurements of the distance between the stratum corneum to the Camper’s fascia and from the stratum
corneum to the muscle we were able to demonstrate that 68% of the patients presented a contraction of the volume of
Conclusions: Based on the demonstrated results with real-time ultrasound scanning, we have observed that 2 RF treatments on the subcutaneous tissue of the buttocks and thighs provide a volumetric contraction effect in the majority of patients. This validates the primary hypothesis of our protocol and establishes that the RF energy works on the connective tissue of the subcuaneous adipose tissue. This effect should be the same on any other body part.
Neil S. Sadick MD FACP FACS
Objective: To determine the safety and efficacy of a light and heat energy (LHE)-based system (SkinStaion® system; Radiancy
Inc, Orangeburg, NY, USA) for hair removal in subjects with skin types V and VI.
Methods: Thirty-one subjects with Fitzpatrick skin types V and VI were consented for treatment with the system.
Twenty-six subjects completed the 12-week follow-up. Safety was evaluated at each visit and efficacy was evaluated at both
Results: An average hair clearance of 41.7% from 57 treatment sites was reported at the 6-week follow-up visit and a
35.5% average hair clearance was reported at the 12-week follow-up. Edema was only reported in 2 cases (7.7%) of the study
population. Eleven cases of erythema were reported following treatment.
Conclusion: Treatment with the modified LHE system was safe and effective for hair removal in patients with skin types V and VI.
Macrene Alexiades-Armenakas MD PhD
Several classes of nonablative laser and light technologies have been developed to target laxity, rhytides, and the
various aspects of photoaging. The combination of the 3 main classes of nonablative rejuvenation, infrared laser, intense
pulsed light, and radiofrequency energy, are assessed in the current study. Using a comprehensive grading scale developed
to evaluate the multiple categories of the aging skin, quantitative analysis of changes in each category as well as overall
improvement and patient satisfaction were calculated. The combination technology resulted in a patient mean (95% CI)
percent improvement per category of 10.9% (8.1% to 13.7%) per treatment and 26% (16.5% to 35.5%) overall following
a mean (±SD) of 2.4 (±1.2) treatments. In addition, the patient satisfaction was 71.4%, suggesting that combining
nonablative technologies may maximize clinical results and patient detection of improvement.
Robert A. Weiss MD, Michael Gold MD, Natalie Bene MD, Julie A. Biron, Girish Munavalli MD, Margaret Weiss MD, Karen Beasley MD
Background and Objectives: The use of thermal heating in microscopic zones is generically termed “microrejuvenation.” The
objective of this study was to evaluate the benefits of using a novel 1440-nm Nd:YAG laser (Affirm™, Cynosure, Westford,
MA) with a novel approach for microscopic heating. This device utilizes a microarray of lenses delivering a 10-mm beam as
hundreds of high-fluence beamlets interspersed with a relatively uniform low-fluence background irradiation.
Study Design: Forty subjects (N = 40) at 2 study sites presenting with superficial rhytides and other symptoms of
photoaging or scars received 3 treatments at 4-week intervals using a T-250 lens array. Total fluence ranged from 3.0 to 7.0
J/cm2. Zimmer air cooling was used for all treatments. No topical anesthetic was required.
Results: The most common immediate and expected clinical effects were erythema and edema lasting less than 24 hours,
although 6 patients reported edema lasting for up to 1 week. There were no permanent side effects. In total, 2.7% of treatments
resulted in temporary side effects, the most significant of which was a slight depression on the cheek (n = 1), which
completely resolved within 3.5 months. Other side effects included localized areas of acneiform subcutaneous erythematous
papules (n = 4) and a linear superficial crust (n = 1) with the original tip, all of which resolved within 1 week. One patient
reported small erythematous subcutaneous nodules resolving in 17 days. Tenderness of the neck lasting from 2 weeks (n = 2)
to 3 weeks (n = 1) was also reported.
Results: In all, 92% of the patients completed 3 treatments. Of these, 85% completed the 1-month follow-up. At the
follow-up, 94% of subjects exhibited improvement in one or more categories, 82% exhibited mild to moderate improvement,
and 12% exhibited good improvement. Side effects were minimal and included mild posttreatment erythema and edema
resolving within 24 hours. Pain during treatment was judged minimal to moderate. Postauricular histology showed areas of
thermal injury up to 250 ?m deep and 150 ?m wide.
Conclusions: A 1440-nm beam split by a microlens array is a promising new approach for inducing nonablative
neocollagenesis in the remodeling of scars and rhytids. Histologic evidence confirms the microcolumnar nature of callagen heating using this microarray.
David J. Goldberg MD, Snehal Amin MD, Bruce A. Russell MD, Robert Phelps MD, Norma Kellett MD, Laurence A. Reilly MD
Objectives: To evaluate the clinical efficacy and ultrastructural changes in photodamaged skin after combined 633-nm and
830-nm light-emitting diode (LED) treatments.
Methods: Thirty-six subjects received 9 LED treatments over the course of 5 weeks and were subsequently evaluated for final
clinical improvement 12 weeks after treatment. Five subjects were also biopsied to determine the ultrastuctural posttreatment
changes in collagen fibers.
Results: A statistically significant improvement in wrinkles was seen after profilometric analysis. The majority of subjects
reported improvements in softness, smoothness, and firmness at all time points. Electron microscopic analysis showed evidence
of post-LED treatment of thicker collagen fibers.
Conclusions: 633-nm and 830-nm LED treatments play a role in the treatment of photodamaged skin. LED treatments can be used as either a primary or adjunctive treatment modality.
Ricardo Ruiz-Rodriguez MD PhD, Laura López-Rodriguez MD
As demand for less invasive, highly effective cosmetic procedures grows, dermatologists must continue to explore and
develop new treatment options. Nonablative skin resurfacing techniques offer an effective and noninvasive treatment for
photorejuvenation. Several studies have shown improvement of photodamaged skin and increased collagen production after
nonablative treatments using vascular lasers, mid-infrared lasers, intense pulsed light, radiofrequency devices, fractional
resurfacing, and plasma skin rejuvenation. Among the novel methods for maximizing the efficacy of nonablative treatment
is the concurrent use of a photosensitizing agent. The light sources currently most used for photodynamic rejuvenation are
intense pulsed light and pulsed dye laser. We present some preliminary results on rejuvenation using Metvix and red light.
We are still far from a thorough understanding of the molecular mechanism of rejuvenation with this technique, although a
nonspecific immune response could be involved. Understanding the laser-tissue interactions associated with photodynamic
therapy is crucial in selecting patients that will most likely benefit.
Tina S. Alster MD, Sharleen St. Surin-Lord MD
Photodynamic therapy (PDT) has been used in the treatment of a variety of benign and malignant cutaneous conditions.
More recently, it has been used to enhance the results of skin rejuvenation procedures. The purpose of this article
is to review the current practical applications of PDT in a cosmetic practice.
Amy Forman Taub MD, Eliot F. Battle Jr. MD, Gregory Nikolaidis MD
Modalities for skin tightening include radiofrequency (RF) energy, lasers, and combination RF and diode lasers. A new
broadband infrared light device (BILD) (Titan, Cutera, Inc, Brisbane, CA) targets water to achieve dermal heating and
collagen remodeling for skin tightening. Although thousands of procedures have been performed worldwide with this device,
only one article (to the author’s knowledge) describing its performance in skin tightening has been published.
Three US dermatologists report their experience with and provide their perspective on facial skin tightening with the BILD
system. As early adopters, they each have 12 to 18 months experience with this system. One author (A.F.T.) treated
42 patients twice at 1-month intervals over 18 months. The mean improvement score was 1.83 (scale 0 to 4, with
4 denoting maximum improvement) with an average follow-up time of 3.7 months. More than 90% of treated patients
showed visible improvement. No complications were observed and patient satisfaction was high.
This paper presents the general consensus of the authors on patient selection and treatment protocol, their modifications of
the manufacturer’s treatment protocol, and the outcomes of 42 patients treated by one author (A.F.T.). The observations were
gathered separately and turned out to be very similar. The recommendations are presented to help practitioners achieve
consistently good results and avoid complications with the BILD procedure.
Perry Robins MD, Sherry Hsiung MD
When skin integrity is disrupted during a surgical procedure, its protective barrier becomes compromised and predisposes the
individual to cutaneous infection. Postoperative infection remains a considerable cause of morbidity and mortality. This article
briefly reviews the etiology and management of postoperative infections following dermatologic surgery.
Diane M. Thiboutot MD, Harald P. Gollnick MD
Acne vulgaris is an exceptionally common, chronic, and recurring disease. It involves multiple etiological factors including
follicular hyperkeratinization, increased sebum production, Propionibacterium acnes proliferation, and inflammation.
Presently, oral isotretinoin is the only single agent that is effective against all 4 major pathophysiologic features. However,
this drug is also responsible for several serious side effects, including teratogenicity. Therefore, it should be used in only the
most severe cases and alternative treatment approaches for inflammatory acne, such as initial combination therapy, should
be considered first. Combination therapy in inflammatory acne simultaneously targets multiple pathogenic factors. Current
guidelines recommend early initiation of combination therapy with a topical retinoid and antimicrobials for mild to
moderate inflammatory acne and topical retinoids with oral antibiotics (with or without the use of benzoyl peroxide) for
moderate to severe cases of acne, followed by maintenance therapy with topical retinoids. This review evaluates the
rationale and clinical evidence for the use of adapalene in combination therapy for inflammatory acne.