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 , Brian S. Biesman , Henry Hin Lee Chan , Michael S. Kaminer , Suzanne L. Kilmer , Mary P. Lupo , Ellen Marmur , Susan Van Dyke

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

tations. While there is a comprehensive grading scale for assessment of rhytides, laxity, and photodamage13 this is mainly used to assess the efficacy of cosmetic treatment modalities in the context of a clinical study rather than in routine clinical practice.]

3. Discussing /managing patient expectations prior to treatment with 4th generation non-microneedling monopolar RF is essential. It is always important for patients to have realistic expectations when undergoing any cosmetic procedure. While 4th generation non-microneedling monopolar radiofrequency may improve overall appearance, it is not a surgical treatment and typically does not result in dramatic changes. Managing expectations through frank and honest discussion prior to treatment will lead to improved patient satisfaction. Equally important is to prepare patients for the timing of results. Patients should expect some immediate improvement with continued tightening and smoothing of the skin over the next 2-6 months as new collagen forms.

4. Patients with severe sun damage are not ideal candidates for 4th generation non-microneedling monopolar RF. The panel noted that patients with poor skin quality and mild dyschromia can achieve good results, especially when 4th generation non-microneedling monopolar radiofrequency is used in combination with other treatment modalities.

5. Greater than 90% of properly selected patients may achieve positive results with 4th generation non-microneedling monopolar RF. Based on their one-two years of clinical experience with 4th generation non-microneedling monopolar RF, the expert panel feels that their patients are achieving results equivalent or better than with previous generations. The panel recommends repeating the groundbreaking, 5,700 patient satisfaction survey study undertaken with the first-generation device in 2005 which showed that 87% of patients experienced immediate tightening, 92% observed skin tightening 6 months after treatment, and 94% of patients found the treatment results met their expectations.14

6. Patients in whom positive results are seen may benefit from additional treatments with 4th generation non-microneedling monopolar RF, as results appear to be cumulative. The collagen changes induced by 4th generation non-microneedling monopolar RF don't go away but the aging process continues, so the skin that was tightened will eventually show signs of laxity again. Repeat treatments will help to keep skin tightened and may postpone the need for surgery.

7. 4th generation non-microneedling monopolar RF can be used safely and effectively to treat eyes, face, submentum and body.

8. Most appropriately selected patients see visible improvements after a single 4th generation non-microneedling monopolar RF treatment.

9. Most patients expect to achieve some contouring after 4th generation non-microneedling monopolar RF treatment. Contouring is a subjective term, but may equate to firming, improved elasticity or “shrink-wrapping.” As applied to the jawline, it may imply more definition or angularity (Figures 2A and 2B).

10. Patient feedback on heat sensation scale should be used to select 4th generation non-microneedling monopolar RF treatment settings. It should be hot, but easily tolerable. The discomfort of treatment is related to RF energy converting to heat energy in the skin. Tissue properties such as dermal thickness, fat thickness, fibrous septae, and adnexal structures affect local impedance. Additionally, the ability to tolerate pain varies from patient to patient and by treatment location. The expert consensus panel agreed that 4th generation non-microneedling monopolar RF is more tolerable than previous generations, due to the larger tip size, multi-directional vibration, and cooling cryogen spray. Most sensitive patient’s discomfort can be mitigated by pre-medicating with 800 mg of ibuprofen or 500 mg acetaminophen. For patients with lower pain thresholds, adding low dose oral anxiolytics may be effective. It should be noted that the manufacturer does not recommend the use of sedatives, regional blocks or narcotic pain medications as these may prevent the patient from providing accurate heat sensation feedback which could potentially increase the risk of adverse events. The manufacturer recommends starting with clean dry skin and then applying a generous amount of the provided Coupling Fluid to the targeted site before beginning treatment and reapplying throughout treatment.