Thermi, an Almirall Company (Irving, Texas), has introduced the new ARVATI system, which features advanced temperature-controlled RF EPIC technology. Powered by ThermiRF, the ARVATI offers emission of continuous, powerful RF waves, with an enhanced 50 W capacity system, intelligent software with electrode recognition and a control algorithm, offering speed and control for various modalities, including ThermiTight, ThermiRase and ThermiSmooth Face.
RF and ultrasound devices are also joining the ranks of CoolSculpting from Allergan and SculpSure from Cynosure, a Hologic company, in their ability to sculpt areas around the neck or jawline.
truSculpt 3D, a noninvasive monopolar RF system from Cutera (Brisbane, California, U.S.), which is optimized to deliver targeted, repeatable and uniform sculpting of problem areas, including the neck, without visual downtime.
According to the manufacturer, truSculpt 3D takes a multi-dimensional approach to decrease circumference and permanently eliminate fat by delivering and holding clinically therapeutic temperatures to the subcutaneous adipose tissue to achieve the highest clinical efficacy in the shortest possible treatment time with enhanced safety and comfort.
EmbraceRF by InMode (Richmond Hill, Ontario, Canada), is another new option for addressing loose skin on the neck and jowls. This subdermal adipose remodeling device (SARD) utilizes minimally invasive RF and bipolar RF energy to contract skin, as well as improve textural and fat concerns. In addition, it can be used in combination with liposuction, depending on how much fat is in the treatment area.
Dr. Soriano has been observing a new Asian beauty trend in recent years.
“In the last five years, the trend has been to convert round chubby faces, which present a childlike appearance, to a more V-shaped face, which gives a more mature, sophisticated look,” Dr. Soriano said. “In my practice, this is best achieved with several sessions of unipolar radiofrequency treatments on the mandibular and submandibular areas of the face, in combination with toxin injections to the masseter.”
For Dr. Soriano, the Reshape RF from Alma Lasers is her favorite energy-based device for achieving dramatic, consistent and reproducible face reshaping, lifting, toning, firming and tightening.
It is important to note that providers and patients using bulk heating RF for facial rejuvenation should think in terms of multiple treatments, maintenance treatments and no downtime.
“My wife comes in and gets her eyes done with an RF device every three or four months. It takes 20 minutes, she’s done and doesn’t need anything else,” Dr. Gold said.
Dr. Gold and colleagues published a study using the Endymed 3Deep, showing lifting and tightening results similar to those experienced in research investigating the Ultherapy device from Merz Aesthetics (Raleigh, N.C.). “Using very high RF energies, we obtained nice tightening and showed lifting, comparatively,” Dr. Gold reported.
High intensity focused ultrasound (HIFU) energy is among the leading approaches that physicians worldwide use to lift and tighten the skin. Yu-Hao Huang, M.D., a plastic surgeon and director of the International Aesthetic Center in Kaohsiung City, Taiwan, uses the HIFU-based device Ultraformer, from Classys (Korea), for facial tightening and minimal lifting on Asian skin. The Ultraformer is designed to treat Asian skin types, as its parameters are based on clinical studies with Asian patients, Dr. Huang reported.
The Ultraformer III treats elasticity loss on the face, neck and décolletage, “and there’s no downtime for patients,” Dr. Rümmelein said. “HIFU results in micro-damages in several levels under the skin, which induces repair mechanisms.”
As the third version of the Doublo series from Hironic (Gyeonggi-do, South Korea), the Doublo Gold’s HIFU technology allows physicians to target the superficial musculoaponeurotic system (SMAS) and dermis without any incision or damage to surrounding tissue. By delivering thermal energy 3 mm to 4 mm into the skin, treatment regenerates collagen for skin tightening, while diminishing wrinkles and rejuvenating the face.
The SygmaLift by Medixsysteme (Ruggell, Liechtenstein) is another example of an energy-based system that has evolved to not only lift, but also contour and remodel the face. The synergism of the thermal and mechanical actions of focal ultrasound energy results in effective treatments that accentuate the neck and jawline, contour the eyes and lift the eyebrows.
With no surgery or incision required, SygmaLift is ideal for those who want firm and younger-looking skin. It is not just a facial lifting system, but also a facial remodeling option due to its ability to deliver energy to a depth of 5 mm. This creates safe warming of the targeted tissues non-invasively from the inside out, stimulating collagen and skin regeneration.
FDA-cleared to lift skin of the neck, non-surgical Ultherapy has been established as the go-to device for treatment of submental skin laxity, jawline laxity and jowls.
“Ultherapy is microfocused fractional ultrasound, it is very safe and there’s no question it works,” Dr. Gold stated. “You have to do it properly and control any discomfort, but Ulthera is usually just one treatment; two, rarely.”
In addition to Ultherapy, Dr. Fabi also uses ThermiRF primarily for the neck. “I like to reserve this for patients that have a little bit of fat because when you run the RF probe within adipose tissue you can obtain a little bit of fat destruction,” she said.
The key, according to Dr. Gold, is to determine whether patients’ submental fullness is from fat or skin laxity. If it is from fat, Dr. Gold uses CoolSculpting CoolMini or Kybella, both from Allergan (Irvine, Calif.); if the problem is skin laxity, he uses Ultherapy.
Dr. De Boulle addresses excessive submental fat in some patients with CoolSculpting’s Cool Mini from Allergan.
“CoolSculpting Mini for submental fat is perfect,” he said. “It is a reliable and standardized procedure. It will not do anything for the lines, but it will help in reducing submental fat and providing a tightening of the overall skin against the deeper tissue. So, the cervicomental angle will be better.”
SculpSure from Hologic, Inc. (Marlborough, Mass.) is another device that is FDA cleared to address the double chin. Application of this 1060 nm hyperthermic diode laser heats subcutaneous adipose tissue to disrupt fat cells, leaving extracellular lipids and cellular debris to be naturally removed by the body.
However, as Dr. De Boulle pointed out, excess fat isn’t the only concern people have with their necks. Patients often request treatment of the horizontal and vertical lines that may appear with age.
While Dr. De Boulle specified that a surgical neck lift is the leading solution to address horizonal bands, he said there is one exception – skin tightening, and he has achieved notable success in diminishing horizontal lines on the neck with RF microneedling.
“I think the Infini (Lutronic) is one device that I’ve seen that has a certain percentage of success in reducing these lines,” Dr. De Boulle denoted. “And unlike surgery, the advantage of RF microneedling is the minimal downtime, which is not dramatic. Patients have a couple of days of scabs and redness.”
Conversely, none of today’s devices will treat the vertical lines on the neck – the “platysmal bands.” These are best treated with neuromodulators, Dr. De Boulle added.
While energy-based devices don’t volumize in the way that traditional injectable fillers do, they can thicken the dermis by stimulating collagen production, Dr. Fabi explained.
Roy G. Geronemus, M.D., director of the Laser & Skin Surgery Center of New York and clinical professor of dermatology, New York University Medical Center, said his go-to devices for collagen formation include non-ablative and ablative fractional devices, such as Lutronic’s LaseMD, Valeant’s Clear + Brilliant, Fraxel Dual or Fraxel Repair, as well as Sciton’s Halo hybrid fractional laser.
Some devices combine RF with microneedling. These systems are among the energy-based technologies that encourage collagen production.
In Dr. Rümmelein’s experience, the single best device for facial aging is RF microneedling with Infini.
Infini delivers RF energy via insulated needles at varying customizable depths. The insulation protects the epidermis from electrothermal damage, which reduces downtime and risk of post-inflammatory hyperpigmentation (PIH), while heating the deeper tissues to achieve coagulation. Research has shown that heating the dermis to a high enough temperature will cause collagen coagulation, which results in neocollagenesis and neoelastinogenesis. During this remodeling process, new collagen gradually replaces the old, leading to skin tightening.
According to Dr. Gold, RF microneedling offers patient benefits with a few drawbacks.
“Microneedling with RF is a little more invasive because of the needles so there’s more pain,” he elaborated. “But patients need fewer treatments. Maintenance is often pushed out about a year in most cases. And you achieve good tightening and a nice lift.”
Dr. Gold’s go-to options in this category are: Endymed’s Intensif, Lutronic’s Infini, InMode’s Fractora, Venus Legacy’s Viva and Jeisys Medical’s INTRACel (distributed in the U.S. by Perigee Medical).
Dr. De Boulle also favors RF microneedling with the Infini to address facial skin aging concerns, including skin tightening.
“When you apply the Infini, the RF current passes through a needle cushion of 7 by 7 gold-coated needles at different depths and different passes,” he stated. “This causes the collagen fiber bundles to shrink in all directions. We use the Infini as adjunctive therapy.”
Dr. Walden recommends RF microneedling to improve facial texture and for mild to moderate firming or tightening.
“I would advise doing treatments on a regular basis, so every three to four months for maintenance,” she said.
Recently, Dr. Walden opted for the Vivace device from Aesthetics Biomedical (Phoenix, Ariz.) for her medspa. This system uniquely features not only RF microneedling, but also LED technology for pigment.
“It is a combination treatment in one device,” she stated. Vivace provides a minimally invasive treatment that stimulates the natural production of collagen and is shown to be effective in alleviating facial wrinkles and fine lines, as well as tightening and toning the face and neck. The results are immediate and also improve over time, giving patients the best of both worlds.
Other RF microneedling systems include the recently FDA approved PiXel8-RF from Rohrer Aesthetics (Homewood, Ala.). Using bipolar RF, which is safe for all skin types, alongside minimally invasive insulated or non-insulated microneedles, the PiXel8-RF facilitates non-surgical skin tightening. During treatment, heat is driven deep within the skin layers to stimulate collagen and cause elastin cells to regenerate, resulting in a firmer, smoother and more consistent skin surface.
Cutera’s Secret RF is another novel fractional RF microneedling system designed to stimulate and remodel collagen, and address the common signs of aging. By adjusting the microneedles, Secret RF can deliver energy at various depths so that treatments can be tailored to deal with each patient’s individual concerns, such as fine lines and wrinkles.
The Legend Pro from Lumenis uniquely features RF assist microneedling and Tripollar RF. By delivering RF energy via three or more electrodes, treatment induces controlled heating of the deep dermis, initiating collagen and elastin fiber regeneration.
Profound from Syneron Candela (Wayland, Mass.) is a bipolar RF system that utilizes five pairs of microneedle electrodes to deliver fractionated thermal injuries in the deep reticular dermis where the concentration of collagen is the highest. This thermal injury stimulates dermal remodeling and new elastin, collagen and hyaluronic acid formation. Study findings show a 100% response rate for rhytides and 95% response rate for laxity at six months post-treatment. Profound can be used to restore dermal volume loss, treat nasolabial and melolabial folds, jowls, submental and submandibular redundancy.
Dermatrix Duo from GSD (Shenzhen, Guangdong, China) combines microneedle and needle-free fractional RF technology for skin resurfacing, wrinkle reduction, skin tightening and more. In a controlled manner, the microneedle handpiece can penetrate deep into different skin layers, while the needle-free handpiece acts on more superficial areas. And as a non-laser technology, treatment is safe for all skin types, even darker, pigmented patients.
While there are contrasting attitudes and beliefs surrounding microneedling, in Dr. Gold’s opinion, “Suboptimal outcomes might result from not using sufficient energy or doing enough treatments, but ample studies have been done that show if you use RF needles properly, you can attain incredible results.”
Dr. Geronemus recently published case reports in Plastic and Reconstructive Surgery illustrating his use of the Infini high-intensity focused RF microneedling device to treat festoons.2
“Historically, these fluid-filled pouches on the upper malar portion of the cheek have been very difficult to remove. Over the years, physicians have tried surgery, ablative lasers and even injecting tetracycline in the malar pouches with minimal success,” Dr. Geronemus said. “We’ve had considerable benefit with a mildly invasive technique utilizing RF microneedling.”
