Consensus Recommendations for 4th Generation Non-Microneedling Monopolar Radiofrequency for Skin Tightening: A Delphi Consensus Panel

January 2020 | Volume 19 | Issue 1 | Original Article | 20 | Copyright © January 2020

Published online December 13, 2019

Anne Chapas MD,a Brian S. Biesman MD,b Henry Hin Lee Chan MD,c Michael S. Kaminer MD,dSuzanne L. Kilmer,e Mary P. Lupo MD,f Ellen Marmur,g Susan Van Dyke MDh

aUnion Square Laser Dermatology, New York, NY bBrian S. Biesman PLLC, Nashville, TN cHong Kong Dermatology and Laser Center, Hong Kong dSkin Care Physicians, Chestnut Hill, MA eLaser & Skin Surgery Center of Northern California, Sacramento, CA fLupo Center for Aesthetic & General Dermatology LLC, New Orleans, LA gMarmur Medical, New York, NY hVan Dyke Aesthetics, Paradise Valley, AZ

IMPORTANCE: The demand for non-invasive methods for facial and body rejuvenation has experienced exponential growth over the last two decades. While multiple treatment systems exist, device specific guidelines to help guide clinicians to achieve the best outcomes are lacking.

OBJECTIVE: To develop expert consensus on the use of 4th generation non-microneedling monopolar radiofrequency. Design: In a modified Delphi process, a panel of 8 international experts in aesthetic dermatology participated in 3 rounds of consensus building commencing in April 2019. Initially, 32 consensus statements were developed addressing patient selection, patient outcomes, treatment settings, and practical use of non-microneedling monopolar radiofrequency. By the 3rd round, these had been reduced and refined to a total of 19 statements. The consensus process was completed in June 2019 and the data were analyzed in July 2019.

RESULTS: In 3 Delphi rounds, the 8 panelists achieved consensus on 19 recommendations on the use of 4th generation non-microneedling monopolar radiofrequency and developed additional explanatory guidance to support 12 of the consensus statements including those related to patient selection, procedural technique, and anticipated treatment outcomes.

CONCLUSIONS AND RELEVANCE: Although guidelines will never replace individual clinical judgment, as the demand for noninvasive tissue tightening increases, so too does the need for positive, reproducible outcomes. Careful patient selection, pre-treatment counseling, treatment planning, and good technique, are all critical for success. These consensus statements should assist clinicians in each of these areas.

J Drugs Dermatol. 2020;19(1):20-26. doi:10.36849/JDD.2020.4807


The increasing demand for safe and effective, non-surgical, skin rejuvenation modalities has resulted in a paradigm shift in the fields of dermatology and aesthetic medicine. Although surgical procedures and ablative laser technology produce dramatic results, many patients opt for procedures with minimal or no downtime, minimal discomfort, and a lower risk of side effects and complications. Several minimally invasive skin rejuvenation procedures help improve skin texture, reducing the appearance of fine lines, wrinkles, and acne scars. The goal of most non-invasive skin rejuvenation procedures is to trigger a wound repair response, encouraging the body to replenish or remodel old or damaged tissues. The process may be mechanical, chemical, or thermal. Non-surgical thermal skin tightening procedures work by using targeted energy to heat deeper layers of skin, which stimulates collagen and elastin production and gradually improve skin texture. Non-invasive options for skin tightening include focused ultrasound, non-ablative lasers, and radiofrequency (RF).

One such system, a non-microneedling monopolar RF system (Thermage FLX®, Solta Medical) is a capacitively coupled monopolar radiofrequency system that utilizes a reverse thermal gradient that has been in use since 2002. The fourth generation system, approved by the U.S. FDA in 2017, includes enhanced features such as optimized energy delivery, shorter treatment times, uniform energy delivery over the tip, multiple tip sizes, enhanced multi-directional vibration, a universal handpiece for all tips, and a larger 4cm tip size that reduces treatment time