INTRODUCTION
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.
CASE REPORT
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.
DISCUSSION
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
