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

11. Energy settings can be titrated up or down based on the patient’s comfort level. Use a 0-4 patient feedback scale with a target goal of 2 – 2.5 (Figure 3).

12. 4th generation non-microneedling monopolar RF treatments should be repeated approximately every 12 months to maintain results and to continue to induce further skin tightening and smoothing. Some patients may choose to “touch-up” in 6-months, others may wait up to 2 years to repeat. Treatment interval decisions may be based on patient age, what the patient wants to achieve / avoid and financial considerations.

13. 4th generation non-microneedling monopolar RF can be used in patients who have, or will, receive neurotoxins, dermal fillers and fractionated skin resurfacing ablative and/or non-ablative laser modalities, based on medical judgment.

14. When adding therapies, 4th generation non-microneedling monopolar RF may be done before, or after the other treatment depending on medical judgment, schedules and convenience for the patient. Should not be done on erythematous skin, ie, immediately post fractional laser.

15. The wait period between 4th generation non-microneedling monopolar RF and injecting dermal fillers is based on patient preference and clinician judgment.

16. The wait period between 4th generation non-microneedling monopolar RF and injecting neurotoxins is based on patient preference and clinician judgment.

17. 4th generation non-microneedling monopolar RF treatmentrelated side effects are very rare and generally mild. To prevent superficial burns or other tissue damage, clinicians are urged to inspect the treatment tip membrane before, and periodically during, treatment to ensure integrity and to regularly apply generous amounts of coupling fluid. Of note, the historical concerns about fat atrophy, associated with earlier generations of the device, have not been observed with the current generation device. Furthermore, since the launch of the 4th generation non-microneedling monopolar radiofrequency device, the overall incidence rate of adverse events reported to the manufacturer, based on their sales of treatment tips equates to less than 0.05%.15

18. Patients who are treated with 4th generation non-microneedling monopolar RF every 1-2 years may experience prolonged, consistent skin tightening that could help to prevent future sagging.

19. Achieving favorable results with 4th generation non-microneedling monopolar RF is dependent upon following proper patient selection and treatment guidelines, together with good technique. Good technique constitutes 2-4 passes using moderate treatment levels, using the patient feedback scale where the treatment goal is hot but tolerable. The multiple passes are followed by 5 –10 vector and contouring passes, treating to the clinical endpoint of visible or palpable tightness.


Skin laxity and wrinkling are major findings associated with aging. The demand for noninvasive methods to decrease skin laxity and smooth irregular body contours has experienced exponential growth over the last two decades. Non-ablative aesthetic RF treatments have established a good safety record and are associated with minimal to zero downtime. The mechanism of action is based on an oscillating electrical current, forcing collisions between charged molecules and ions, which are then transformed into heat. RF generated tissue heating has different biologic and clinical effects, depending on the depth of tissue targeted, the frequency used, and specific cooling of the dermis and epidermis. A study that examined the thermoelastic response of cutaneous and subcutaneous tissues to RF heating demonstrated that there is greater power absorption in the fibrous septa filaments than in fat.16 Heat disrupts hydrogen bonds of collagen molecules resulting in conformational changes. The denatured collagen fibrils immediately contract and then act as a tightened scaffold over which new collagen is laid down in the secondary / repair phase of wound healing, giving rise to skin tightening.17 RF device settings and the number of treatment passes were shown in one study to have an important effect on collagen fibril change.18 Increases in pass number at the same setting dramatically increased the extent of irrevers-