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

ible collagen fibril change, specifically, increase in diameter, as did increases in energy setting at a standard pass number.18 The depth of penetration of RF energy is inversely proportional to the frequency. Consequently, lower frequencies of RF are able to penetrate more deeply into the dermal layers to stimulate collagen contraction and neocollagenesis.19

RF devices may be monopolar, bipolar, tripolar, polypolar, or combination. Monopolar systems deliver current through a single contact point with an accompanying grounding pad that serves as a low resistance path for current flow to complete the electrical circuit. Monopolar electrodes concentrate most of their energy near the point of contact and energy rapidly diminishes as the current flows toward the return pad.

The 4th generation non-microneedling RF system uses a highfrequency generator that produces a 400W, 6.78MHz monopolar current signal. A disposable membrane tip with a treatment area of 0.25, 3.0, 4.0, or 16.0cm2 is used with a disposable adhesive return pad that serves as the passive electrode. The depth of heating is dependent upon the size and geometry of the treatment tip being used. A conductive coupling fluid is used during the treatment to enhance the thermal and electrical contact between the treatment tip and the skin. The treatment tip creates an electrical field within the tissue by alternating its charge from positive to negative 6 million times per second with electrons and ions simultaneously attracted and repelled from the surface. The movement of these ions generates heat which results in immediate collagen denaturation with resultant fibril contraction and tissue thickening.20 A secondary inflammatory wound healing response follows, resulting in collagen neogenesis, deposition and remodeling along with gradual reduction in rhytides, tissue tightening, and improvement in skin texture in most patients. Skin surface cooling is maintained through the use of a cryogen gas spray, while comfort is improved by use of vibration and adjusting energy level of the handpiece according to patient feedback.

Recommended treatment algorithms with the RF device have significantly changed since their introduction to the U.S. marketplace nearly 18 years ago. Initially, patients were treated with a single pass of the RF device at high-energy settings, sometimes resulting in mixed clinical results and significant treatment discomfort. Subsequent treatment guidelines used a multiple pass technique with reduced energy settings, resulting in superior clinical results and significant reduction in patient discomfort.12,19,21

In developing these Consensus Statements, we aimed to provide clear, unambiguous practical guidance for clinicians. However, we have steered away from providing numerical recommendations for treatment settings or retreatment intervals. For example, energy level selection is best determined by continuously evaluating the level of heat tolerance for individual patients during the procedure. Not only do patients have different pain tolerance but they also vary in skin composition, which in turn affects RF penetration, resistance and thermal deposition within tissues. As such, each patient’s feedback regarding tolerability is vital during treatment to avoid excessive thermal delivery to the skin.

Although there is an extensive body of clinical literature to support non-microneedling monopolar RF, and consensus panel recommendations have been published for previous generations of the device, these consensus statements represent the first, real-world, practical treatment guidelines for the 4th generation non-microneedling monopolar RF. While we recognize that each patient is unique and that guidelines will never replace individual clinical judgment, as the demand for noninvasive tissue tightening increases, so too does the need for positive, reproducible outcomes. Although improvement in skin laxity is not as pronounced as that observed with surgical lifting procedures, the advantages of RF procedures include a virtually nonexistent postoperative recovery period and extraordinarily low risk of serious adverse effects. Careful patient selection, pretreatment counseling, managing patient expectations regarding potentially modest results, thorough treatment planning and good technique are all critical for success.

Doctors routinely rely on the scientific literature in addition to their own knowledge and experience when optimizing treatment for their patients. However, when no such literature exists, and a device is new to the market, additional tools, including these Consensus Statements, will assist clinicians to achieve successful outcomes for their patients.

All guidelines have potential limitations, the most important of which is that recommendations may be incorrect for individual patients. Although these Consensus Statements were developed by internationally recognized experts in aesthetic dermatology, following a precise and transparent methodology, development of Consensus Statements is less rigorous than for evidence-based Clinical Guidelines. Furthermore, we lacked a systemic review of the literature, simply because the literature did not exist.

Given that patient expectations and outcomes represent an important aspect of this RF treatment modality, it could be argued that we should have diversified our expert to include other contributors, including patients.

Other limitations relate to the selected methodology. Although there are many advantages to using the Delphi technique, there are some important drawbacks. First, judgments in the second and subsequent rounds may be influenced by feedback giv-