Multiple Facial Burns With the New Thermage CPT System
November 2011 | Volume 10 | Issue 11 | Case Report | 1320 | Copyright © 2011
Flor A. Mayoral MD and Janelle M. Vega
A 45-year-old man requested treatment with Thermage for skin tightening. He was treated with the new Thermage CPT system and received several facial burns due to failure of the dielectric membrane. It may be contraindicated to treat male patients with this system.
J Drugs Dermatol. 2011;10(11):1320-1321.
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Since its approval in 2002, the use of radiofrequency for tightening the skin in the cosmetic dermatology realm has seen several innovations in technology.1,2 Many companies have developed devices with unipolar, bipolar,3,4 phase-controlled bipolar and now even tripolar devices for the delivery of energy.5 Several systems deliver radiofrequency in a fractional manner and it is often combined with light and/or lasers.6,7 The other methods for skin tightening, infrared light and ultrasound, have also seen several evolutions and changes in the way the energy is delivered to the tissue.8,9 The first company to market radiofrequency for tissue tightening was Thermage. Their initial 1 cm square tip took about four seconds to deliver a single pulse of energy. There are now several tip sizes, from 0.25 cm2 to 16 cm2, and several choices of treatment depths.10 The tips have become faster and larger, and their latest innovation, the Comfort Pulse Technology System-or CPT system-is meant to significantly improve patient comfort and efficacy by delivering radiofrequency in a pulsed fashion, intertwined with bursts of cooling, and by vibrating while delivering each pulse. We hereby report a case of multiple facial burns caused while using this system on a male patient.
In November 2009, a 28-year-old male patient requested Thermage for tightening of the skin. The patient had shaved before coming to the office and the treatment was started on the left side of the face with a 3 cm2 600-pulse CPT tip. As per our usual protocol, several passes were done on the left side of the face and neck. The patient had not complained of any undue discomfort and the tip had not malfunctioned during the treatment. Energy was adjusted according to the patient’s comfort level. Energy levels ranged between 2.5 and 3.5. After treating the cheek and neck, treatment of the chin was begun. The treatment was stopped after a few pulses had been delivered to the chin because several shallow ulcers were noted in the area. Upon close examination, the patient had failed to completely shave some hairs on the chin and neck areas. The left cheek had several minute red papules, most of which were perifollicular. The tip surface was inspected, and there was a burn hole in the center membrane. The patient was shown the tiny ulcerations and a new 3 cm2 600-pulse non-CPT treatment tip was placed on the hand piece. The vibration was turned off and the treatment was continued to completion. Over the next several days, the patient was seen on three separate occasions. It was now obvious that the perifollicular papules had been tiny burns, since all of them were crusted and were healing at the same rate as the chin ulcers. Initially, all of the superficial burns healed with hyperpigmentation. After two months, the dark color has faded, and the only areas that are slightly noticeable as shallow depressions in the chin area were the larger burns caused by the tip.
In the most recent modification to this monopolar radiofrequency device, three simultaneous changes were effected–the energy delivery was altered, the hand piece now vibrates, and a frame was added to each tip. Thermage based the changes in their software for the delivery of energy on transepidermal nerve stimulation (TENS) therapy, and the energy is emitted in alternating bursts of radiofrequency and cold at unequal intervals in an attempt to confuse the neural system and scramble how the brain perceives the pain. In a recent literature review of this kind of therapy, Binder and Baron conclude that although this type of nerve stimulation has been in clinical use for over 40 years, the only disorder TENS should be considered for is the treatment of painful diabetic neuropathy, and that there really is no real evidence of its clinical efficacy based on the published literature