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Radiofrequency (RF) energy treatment is technology for non-surgical tightening of the early signs of loose or sagging skin; ideal for those people who either don’t want, or don’t believe they are old enough to have a surgical procedure. Pure RF energy alone (such as the Accent™, Pelleve™, Thermage™ and Tripollar™ devices) is primarily used to treat skin laxity by facial tightening, and is best suited to patients with mild to moderate sagging of facial tissues, usually those in their mid 30s to 50s, with any skin colour. It is commonly used to treat the forehead, under the eyes, cheeks, mid-face, jaw line, and neck. Based on current RF technologies, most people should see at least a mild improvement in their skin tightness, with minimal risks and downtime compared to surgery. Prices for radiofrequency facial tightening treatment depend on the area(s) treated and the device used.
The 3D-lipo system combines hand pieces for cryolipolysis, radiofrequency, cavitation, dermology and shockwave therapy to achieve skin tightening, cellulite reduction and body contouring.
The Accent system boasts dual handpieces – a bipolar one for volumetric dermal heating, aimed at skin tightening treatments; and a Unipolar one for for fat reduction and cellulite treatment.
EndyMed’s 3DEEP RF applicators use radiofrequency technology to firm, tighten and lift sagging skin on the face and body by heating the collagen in the dermis.
Exilis® Elite uses a combination of monopolar radio frequency (RF) energy, ultrasound to stimulate fat lipolysis (the breakdown of fat cells) and collagen remodelling (for skin tightening), alongside skin cooking, helping to contour the body and face.
The INTRAcel Fractional Radiofrequency (RF) Micro-Needling system is comprised of a Fractional RF Microneedle™ (FRM) array that assists in skin rejuvenation and also treats acne, provides a non-surgical face lift, reduces large pores and acne scarring through a variable radiofrequency power
The Pellevé Wrinkle Reduction System precisely delivers energy to the dermal tissue using advanced radiowave technology to induce collagen contraction without damaging the epidermis. The result is noticeable improvement in skin quality and appearance.
The ProMax Lipo is a combined radiofrequency, ultrasonic cavitation and vacuum massage device for facial skin tightening and body contouring.
The Thermage™ system is a mono-polar (one electrode) radiofrequency device that delivers radiofrequency energy deep into dermal tissues for facial skin tightening, body contouring and improvement in the appearance of cellulite.
TriPollar™ radio frequency (RF) technology is available via two devices, Apollo® and Regen®. The devices are marketed for cellulite reduction, body remodelling and skin tightening.
The use of electric currents in medicine has been documented almost since electricity itself was discovered.
Radiofrequency (RF) surgery has a lengthy history of use in oral, ophthalmic, plastic, and gynaecological surgery of over 70 years. Gradually, its use in the practice of dermatology, cosmetology, cardiology, neurosurgery, hepatology, and ENT procedures gained momentum and popularity. Low frequency alternating currents are also used in physiotherapy for their ability to cause contractions in muscles. RF surgery traditionally utilizes a wave of electrons to cause frictional heating of tissues to incise, excise, ablate or coagulate the targeted tissue.
However with recent developments in cryogenics (the use of extremely cold substances) and information technology, non-ablative RF energy is the newest addition to the treatment options available for the ageing face. With the introduction of cryogenics it is possible to deliver RF energy to the deep dermis and sub-dermal layers of the skin, whilst protecting the epidermis. Heating in this area, without damaging the outer layers of skin, causes microscopic changes to the tissues and collagen contraction, with subsequent collagen remodelling over the months that pass.
Figures from the American Society for Aesthetic Plastic Surgery (ASAPS) indicate that non-surgical skin tightening was the seventh most common non-surgical cosmetic treatment in the U.S.A. in 2016 with nearly 526,700 treatments performed in that year.
If you are considering an RF treatment, the following information will give you a basic understanding of the procedure. It can't answer all your questions, since a lot depends on the individual patient and the practitioner. Please ask a practitioner about anything you don't understand.
What Is It?
Technically speaking, radiofrequency is the number of oscillations (or waves) per second of the electric and magnetic fields within the radio waves portion of the electromagnetic spectrum.
It is lowest of the electromagnetic radiation frequencies within the spectrum, which itself spans from radio waves, microwaves, infrared, optical (visible light), ultraviolet, x-rays, to gamma rays.
By feeding an alternating current (AC) or voltage through an antenna or electrode, electromagnetic waves can be generated that radiate through space at the speed of light; called radio waves. Radiofrequencies, or radio waves, have wavelengths ranging from less than a centimetre to as long as 100 kilometres.
UK domestic electricity which itself is an alternating current could in theory be used for “electrosurgery”, however as most people know, contact with this kind of electric current can cause very undesirable effects such as electrocution and uncontrolled neuromuscular (nerve and muscle) stimulation. However, if the frequency of the alternating current is raised above the response time of neuromuscular structures, we find the radiofrequency range which can safely be used for medical/surgical applications.
By applying RF energy to the human body, which can conduct current and therefore act as part of the electrical circuit, any resistance encountered by the energy flow will cause heat to be produced at the site of maximum resistance, which can also be used to cut or coagulate tissue.
RF energy when used for skin tightening is able to penetrate deep into the skin and affect the deeper dermis and subcutaneous layers, causing tightening and improvements to the underlying tissue structure, but with little change in skin texture or fine lines and wrinkling
Types of Radiofrequency
Monopolar (also called Unipolar)
Monopolar or unipolar refers to a device having one pole or electrode.
With monopolar delivery, the current from the generating machine flows through the body from a single electrode (handpiece) and meets maximum resistance in the area around the tip of the handpiece, where tissue heating in the subdermal layers then occurs. A grounding, or “return pad” may also be used, attached to the patient’s lower back or abdomen, to provide a low resistance path for the current to flow back to the generating machine, to complete the electrical circuit.
An example of a monopolar RF only device used for facial rejuvenation and available in the UK is Thermage®.
Biopolar refers to a device having two poles or electrodes.
With bipolar delivery, the current from the generating machine flows only through the tissue which is between the two electrodes on the handpiece; these electrodes start and complete the electrical circuit. Hence, with bipolar delivery, no current flows through the rest of the body, so no grounding or return pad is needed.
In all cases of radiofrequency delivery types, it is the resistance to the current flow in the tissue, not the electrode that generates the heating effect.
There are currently only a small number of RF only devices within the UK market place, targeted mainly at the process of facial rejuvenation via skin tightening; these include:
The Thermage™ system is a monopolar RF device that uses patented technology within its ThermaTip™ to deliver RF energy deep into dermal tissues. This heating action causes deep collagen structures in the skin to immediately tighten. Over time, new collagen is produced by the body to further tighten the skin.
It was cleared by the U.S. Food and Drug Administration (FDA) in November 2002 for non-invasive treatment around the eyes, and then in June 2004 for the treatment of facial wrinkles, followed by off-face for the non-invasive treatment of wrinkles in January 2006. Thermage wass the first system to receive FDA clearance for non-invasive eyelid treatments which was received in June 2007. It is also FDA cleared for the temporary improvement in the appearance of cellulite (when combined with vibration).
ABC Lasers Ltd
The Accent™ system boasts dual handpieces – a biopolar handpiece for volumetric dermal heating, aimed primarily at skin tightening treatments; and a monopolar one for a deep controlled penetration depth of the RF energy for fat reduction and cellulite treatment.
It was awarded a CE Mark in June 2005 for cellulite reduction, and FDA approval for the treatment of wrinkles in April 2007, with further approval for more applications currently pending.
TriPollar™ radio frequency uses mono-polar and bipolar devices which utilise one or two poles to conduct the RF energy, TriPollar™ RF is claimed to be the only radio frequency technology in the world that simultaneously combines the effects of mono and bi-polar radio frequency in a single treatment, which the manufacturers claim produces better results with less pain.
RF and Other Modalities
Increasingly innovation is producing devices that utilise RF energy in combination with other modalities, which are themselves enhanced by the addition of RF, producing machines able to treat more successfully a wider variety of aesthetic requirements from skin tightening to hair removal and cellulite.
RF in combination with light based technologies has the effect of removing the focal point that the light would normally seek out. For example, ablative carbon dioxide (CO2) lasers used in skin resurfacing seek water within the surface layers of the skin, which it heats up, causing both the water and the outermost layers of the skin to vaporise. Non ablative lasers and IPL however seek colour, such as the skin’s pigment (in the case of tattoo or port wine stain removal), or the colour of a hair follicle for hair removal treatments.
By adding RF energy to these light based technologies, such as IPL or lasers for hair removal treatments, it removes the colour focus and the light delivery is able to effectively be “colour-blind”; hence it can treat hair colours such as blonde, grey and red which previously would not have been dark enough to be a focus for the IPL or laser alone.
Some examples of devices combining RF with other modalities currently available or being developed for a wide variety of applications include:
There are several different machines manufactured by Syneron Ltd, which are powered by their patented elos™ (electro-optical synergy) technology — the combined energy technology that uses bipolar radiofrequency and light energies.
IPL and RF (The Aurora™)
The combined efficacy of Intense Pulsed Light (IPL) energy and bipolar radiofrequency energy in the same machine has greatly increased the predictability, safety and outcomes of basic photorejuvenation treatment.
Red and brown skin discolouration can be removed as, or more effectively than optical (IPL) only technology with fewer risks and downtime. The addition of modest levels of RF has also improved the resolution of fine lines and wrinkles.
The IPL and RF combined therapy also provides effective hair removal and permanent reduction outcomes on light and dark skinned patients, as well as red, blonde and grey haired patients.
Diode Laser and RF (The Polaris™ and The Comet™)
The combined 900nm diode laser and very high RF energy (The Polaris™) has added a new and powerful component to skin rejuvenation.
Multiple treatments of this deep, skin penetrating technology has provided pleasing skin tightening results on the face and body, as well as noticeable wrinkle reduction in more moderate and severe wrinkles.
The diode laser and RF combined technology is also effective on larger thread veins on the legs and face.
An 810nm diode laser and high energy RF (The Comet™) provides very effective, high speed 810nm optical hair removal results, with the added RF benefit of efficacious outcomes in dark skinned, or tanned patients, as well as red, blonde or grey hair.
Infrared and RF (VelaSmooth™ & VelaShape™)
The Velasmooth™ & VelaShape™ combined Infrared and RF energy technology (plus tissue mobilization and suction) has proven to be an effective body contour and fat reduction tool, as well as cellulite reduction tool.
In June 2005, it received FDA approval for temporary reduction in the appearance of cellulite.
Vacuum Assisted RF (Aluma™)
The Aluma™ Skin Renewal system from Lumenis was introduced to the world in February 2005 at the American Academy of Dermatology conference in the USA. It is designed to treat wrinkles and skin laxity via the Lumenis technology called FACES™ (Functional Aspiration Controlled Electrothermal Stimulation), which uses a vacuum assisted bipolar delivery of radiofrequency energy deep into the dermal layer for collagen contraction and renewal.
In October 2005 Lumenis received FDA approval to market The Aluma™ in the United States, as well as in Europe.
What Can It Treat?
Pure RF energy alone is primarily used to treat skin laxity by facial tightening, and is best suited to patients with mild to moderate sagging of facial tissues, usually those in their mid thirties to fifties, with any skin colour.
It is commonly used to treat the forehead (lift brows and tightens forehead skin), under the eyes (thickens skin and tightens and lifts the upper cheek skin), cheeks (lifts slightly and diminishes enlarged pores), mid-face, jaw line (diminishes jowling and sagging along the jaw line), and the neck (tightens skin and diminishes wrinkling of the neck).
However, if there is a significant amount of redundant or sagging skin, often seen in older patients over sixty, this procedure may not show a significant enough improvement and a traditional mid-face, face or brow lift operation may be recommended in order to remove the excess skin, therefore achieving a better result.
In combination with other modalities, as we have discussed above, RF can be used to enhance a variety of treatments including hair removal, photorejuvenation, pigmented and vascular problems, acne treatment and cellulite treatment.
You should try to avoid doing anything that will irritate your skin immediately before treatment. This includes sunbathing (natural or artificial). Practitioners are unlikely to treat someone who has sun burn for example, as they would be more likely to suffer pain from the addition of heat to the already damaged skin; however an established tan would be fine.
Some women find that their skin is more sensitive right before and during their menstrual cycle so if you are a woman, you might want to take this effect on pain threshold into consideration when scheduling your treatment appointment(s).
Careful discussions regarding your reasons for wanting treatment are very important before you begin the treatment. You must also make sure that this treatment can deliver what you want and how you would like to look afterwards. Your practitioner should be able to answer all these questions.
A medical history should also be taken to make sure that there are no reasons why you shouldn’t undertake treatment. You may be asked to sign a consent form which means that you have understood the potential benefits and risks associated with the procedure.
Photographs may also be taken by the practitioner for a "before and after" comparison at a later date.
You may be required to wash your face with soap and warm water prior to your treatment, in order to remove any makeup and skin oils which could interfere with the application of the RF treatment.
A topical anaesthetic cream may then be applied to your skin a short time prior to treatment, to help numb the skin slightly; this will normally be removed using alcohol cleansers immediately before your clinician commences the procedure.
Depending on the device being used and your practitioner, a “treatment grid” ink transfer may then be applied over your face to assist the practitioner in navigating your face whilst delivering the RF energy; helping to assure an even application of the RF and to prevent inadvertent overlapping of treatment.
Again, dependent of the device being used you may be fitted with a single-use, self-adhesive return pad attached to your stomach or back to ground you; normally with monopolar devices.
A coupling gel may then also be applied over your face which acts as an additional barrier between the surface layers of your skin and the handpiece of the device.
Your clinician will then commence the RF treatment working across your face. Once completed a soothing gel or lotion may be applied to your skin.
Immediately following the treatment, your skin will feel tighter, with more tightening improvements appearing gradually over the months after treatment.
Results are said to last up to a couple of years, and a single initial treatment can be enough to produce results in some people (using the Thermage device), depending on skin thickness; however your practitioner will be able to determine a course of treatments specific to you and your needs.
Some people experience mild redness immediately following treatment (similar to a sunburnt look), but this usually disappears quickly. Most people find that they can return to work and normal activities immediately after treatment.
Depending on your practitioner you may be advised to use certain soothing lotions, creams or gels to lightly apply to the treatment area, or possibly cool, moisturising mists to apply as you feel necessary.
Side Effects and Risks
As the treatment is carried out you will experience brief, deep heating sensations every time the RF energy is delivered to your skin and underlying tissue. Devices may have an inbuilt cryogenic capability whereby the handpiece is either chilled or emits a cooling spray before, during and after the RF burst, to protect your skin from the heating, and make the treatment more comfortable.
As each person's pain tolerance and threshold varies, it is difficult to quantify how painful or uncomfortable the treatment is. It also depends on the device used and the power settings for the treatment. Your clinician may offer you anaesthetic options, such as a topical anaesthetic cream applied to your skin prior to treatment, or relaxants and pain management drugs, that can minimize your discomfort.
The most frequently reported side effects of treatment with RF energy are swelling, redness, bumps and blisters on or around the treated area, which typically disappear in a few days or weeks.
One of the most serious potential complications from RF energy treatment is a “depression”; this is attributed to the overheating of underlying tissue causing fat atrophy or excessive tightening, giving you a sunken appearance in the affected area. The occurrence of this also depends on the device used and appears to be only currently reported with the Thermacool™ system. Generally, although further studies and more available data is needed, it is considered that there is a correlation between the occurrence of these depressions and the treatment being given at frequency levels above the manufacturer’s guidelines. It is therefore imperative that you make sure that your practitioner is adequately trained and certified to perform the RF treatment.
No special care is needed after treatment although your practitioner may suggest some of the following:
As long as you are generally healthy and don’t have any skin diseases or infections in the area treated, there are few medical reasons why patients should not undergo this treatment.
People with sensory disturbance to the skin may not be considered good candidates as this could make the reporting of discomfort during the procedure unreliable, leading to potential harm.
Although there is no evidence that this treatment is harmful for pregnant women, you would generally be advised to wait until after you have given birth before embarking upon a course of treatment.
More importantly, people with electrical devices e.g., pacemakers, or metal implants e.g., artificial metal hip joints, heart valves or dental plates, cannot be treated because RF current flowing through the body may interfere with these devices or heat up metal implants, which could be dangerous.
Who Can Do It
Depending on the device used, this procedure is generally available only in the offices of qualified physicians who specialise in cosmetic procedures.
You will not be able to access this treatment via the National Health Service.
Private prices for radiofrequency treatments depend on the area(s) being treated and can range from approximately £1,500 - £2,000 for the forehead and eye areas, £2,500 for the jaw and neck areas to £3,000 - £3,500 for the whole face with Thermage.
Costs are often less for other devices using combined treatments (with laser + RF for example) or the Accent™ bipolar RF machine – however, these usually require multiple treatments and may not be as effective. For example, an Accent™ RF Facial session costs from £350 - £600 depending on the treatment area and the condition of skin. It is recommended to have a course of 4 sessions (once every 3 - 4 weeks).
RF energy treatment is a new and promising technology for non-surgical tightening of the early signs of loose or sagging skin; ideal for those people who either don’t want, or don’t believe they are old enough to have a surgical procedure to resolve their onset of skin laxity.
Based on current RF technologies available, most people should see at least a mild improvement in their skin tightness, with minimal risks and downtime compared to surgery.
It is difficult to assess the differences in results between the differing RF technologies that are currently available, and as this market place expands, we anticipate seeing many more devices introduced, with newer improved treatment methods and protocols to further enhance patient comfort and results.
Before and After Pictures
Images provided courtesy of Sigmacon Ltd.
Chin and jawline before radiofrequency treatment with Thermage® .
Chin and jawline 7 weeks post treatment
Images provided courtesy of Dr John Tanqueray at Mulberry House Clinic.
3 weeks after a single Accent™ facial lift treatment.
2 weeks after 4th treatment with Accent™ on crow's feet around the eyes.
Images provided courtesy of ABC Lasers Ltd.
All before and after photographs are real patients, your results may differ.