rfm Archives | The Aesthetic Clinique

Lasers versus Radiofrequency Microneedling (RFM) for Acne Scars

Traditionally, lasers were the gold standard for acne scars. Specifically, ablative lasers, CO2 and Erbium, have been advocated over the nonablative lasers such as Fraxel 1550. In 2013, radiofrequency microneedling (RFM) was approved in the US and the dominance of lasers for acne scars has come under scrutiny. While there are indications for both technologies, this blog will elucidate the decision tree for which technology to use.

Fundamentally, ablative laser energy (heat) is generated outside the body and is driven into the skin at a temperature that causes ablation (vaporization) of the tissue ~ 100 C. Radiofrequency Microneedling generates it’s heat within the tissue by passing current through it. As the current encounters resistance (impedance), heat is produced to a level of coagulation ~ 65-70 C.

The number one concern with ablative laser is healing. While fractional technologies improve the downtime and risks, outcomes are sacrificed. Sometimes several treatments are recommended to match the results that fully ablative lasers would achieve. Downtimes are still around a week or longer with fractional CO2. More importantly, since the laser heats and ablates the most superficial skin layers, the risk of post inflammatory hyperpigmentation (PIH) is almost unavoidable in skin types 4-6. While PIH is reversible in most cases, it can take months in some cases. Wound care is essential with ablative lasers, particularly use of occlusive emollients, to maintain a moist wound for best healing. Unfortunately, occluding acne prone skin often leads to acne breakouts. When breakouts occur, there is risks of actually creating more acne scarring and becoming counter productive.

Healing with RFM is easier and less risky. While there are devices with uncoated needles, the author only advocates the coated or insulated needles. (Uncoated will have similar healing properties as the lasers). Using coated needles, the only injury to the superficial layers of skin are needle punctures. In essence, the device “bypasses” the epidermis. The heat generated from the RF will be in the deeper aspects of the skin, where there are no melanocytes, the pigment producing cells. While there is swelling, redness, and sometimes bruising, the downtime is less with RFM when compared to ablative lasers, usually 3-4 days (individuals do vary!). More importantly, the skin surface heals quickly (similar to microneedling) and there is no need for occlusive emollients.

The depths of acne scars is highly variable, and there can be superficial and deep scars in the same individual. This is probably the most important factor as to what technology to choose. RFM has the advantage for improving deep scars. While depths of RFM aren’t accurate in most devices, in the Genius they are. The Genius is able to reliably place coagulation zones down to 3.5mm. Of note, 3.5mm is typically much too deep to attack acne scars and typical settings are usually up to 2.5mm. Lasers can typically reach 1.5-1.7mm. The energy delivered diminishes as the pulse goes deeper because the energy is absorbed by the upper layers of the dermis. So for the superficial scars – boxcar specifically – give the advantage to the ablative lasers (Look up Dr. Lim 360 degree laser treatment). Keep in mind that the RFM devices can go superficial and treat boxcar scars too.

RFM

Positives:

Safer for all skin types
Less downtime
Deeper penetration
Less PIH risk
Less wound care
Safe on all areas of the body

Negatives:

Not as good with superficial scars but can still treat them
Doesn’t resurface so no pigmentation improvements

Ablative Laser

Positives:

Good for superficial scars – boxcar
Improves pigmentation

Negatives

Long(er) downtime
Higher risk of PIH in types 4-6
Doesn’t treat deeper scars as well
More wound care that can lead to more acne
Higher risks of infection/scarring than RFM
Can’t be used off-face as safely as RFM

Keep in mind that acne scars require multiple modalities such as TCA Cross, subcision, fillers, skincare, PRP, amniotic growth factors to achieve optimal results. Multiple treatments are always required upfront, but also as the aging process causes collagen and fat pad volume loss.

The 5 Most Popular Instagram Cosmetic Procedures That Don’t Work

Instagram is being used as a marketing tool for all types of industries. Unfortunately, you can’t believe everything you see touted. This is especially true for aesthetic procedures. As with any, make sure you do your research, the before and after pictures are actually comparable and aren’t using lighting “tricks”, and the provider is experienced and reputable.

Lip flip with Botox – This procedure claims that the lip will turn up and make the lip fuller for very little money. If you weaken the muscles around the lips with Botox, there is no way this can end up lifting the lip. It also risks changing the smile, having difficulty with sipping and whistling.
Thread Lifts – The procedure consists of placing barbed sutures just deep to the dermis. The barbs engage into the skin and by pulling laterally and upward, they are supposed to lift and tighten. The posts on Instagram mainly show providers pulling on the sutures and watching the skin move. The problem is the sutures aren’t anchored in most cases and are attached to mobile skin. It’s impossible to lift when the entire are desiring lift is move. In addition, the barbs pull through their attachments very quickly, much sooner than collagen can be created to help anchor the suture. The side effects – visible threads, redness, puckering, pain – are as high as 34% in one study. In the same study, visible improvements were not apparent at 12 months. The noticeable changes in the author’s opinion are extremely mild and can be achieved with fillers in a more predictable and longer lasting correction.
Low Density PRP – PRP is short for platelet rich plasma. Unfortunately, there is no standard and the concentration for PRP is all over the map. In the majority of cases, 10-12cc of blood is being drawn to get 5-6cc of PRP. In these cases, the concentration is only about 2x (2 times the normal blood concentration) and all that has been done is the red blood cells have been removed by centrifugation. The benefits of PRP have been studied and optimal concentration levels to promote angiogenesis (new blood vessel growth) have been shown to be about 6X. If you are getting only a small test tube of blood drawn, you probably aren’t getting much benefit from the PRP.
MicroBotox for Necklace (“Tech Neck”) Lines: Horizontal neck lines are often called “Tech Neck” because some people believe they are caused by look down at your phone or computer. Providers are reporting improvements with injecting Botox in the lines in very small but multiple injections. In the author’s opinion, this is not the correct solution and these require filler +/- RFM (Genius) for optimal results. Static lines are not responsive to Botox. Dynamic wrinkles are what respond to Botox.
Using Radiofrequency That Doesn’t Penetrate Skin for Tightening: When an RF device is used to stimulate skin tightening, it must achieve 65-70 C to achieve coagulation. Anything short of coagulation causes temporary collagen contraction and denaturing but very minimal long-term effects. The epidermis needs to be kept at 42C or lower to avoid burns or hyperpigmentation. It is impossible to achieve coagulation in the dermis and still keep the skin surface at 42C or lower. So all the no downtime skin surface RF devices will need to be performed multiple times, have extremely variable results, and often very poor tightening effects. Optimal RF results require the energy to be introduced beneath the skin surface such as RF microneedling (Infini, Genius) or FaceTite/Accutite.

Remember, it all boils down to science whether a procedure works. If the science doesn’t make sense, the procedure probably doesn’t work.

“How I Treat Axillary Hyperhidrosis” Using RF Microneedling (Genius/Infini)

Consent – include pain, tenderness, infection, inadequate improvement, need for further treatments, PIH, scarring, compensatory sweating elsewhere, hair loss
Starch-iodine sweat test and mark treatment area. Hair must be shaven.
Apply 23%/7% lidocaine/tetracaine topical from Central Ave Pharmacy, Lipothene for at least 1 hour – 1.5 hours. Use 30% lidocaine ointment for darker skin types.
Subsequent analgesia might be needed with either injections using mesoram device and lidocaine with epi mixture (5cc lido w epi/5cc saline/1cc bicarb) or just inject
Pronox (Nitrous oxide mixture “Laughing Gas”) can be used as well.
Clean off ointment with alcohol and clean skin with Hibiclens
Use Zimmer air chiller and/or ice, ice roller, or Frozen C
Perform 1-2 passes with each depth of Genius with breaks after each pass to chill and go to opposite side.
3 depths – 3.5, 3.0, 2.5mm – go deep to superficial with subsequent passes
Energy/pin 40-60mj. Lower energies in darker skin types, poor pain tolerance
(For Infini – Treatment level 3-5, 300-400msec if tolerated)
Use sterile technique throughout – sterile gauze, sterile gloves, sterile saline
Keep eye on skin reaction – avoid excessive heat build up, redness. Abort procedure if skin not tolerating energies.
Infrared camera, if available, to monitor skin surface temperature – stay below 42C
Clean skin with sterile gauze and saline.
Apply Clindamycin gel.
In darker skin types, consider 4% hydroquinone 1 week prior and for 4-6 weeks after.
Expect decreased sweat in less than one week.
Repeat treatment in 6 weeks or longer.
2-3 treatments needed to have “controllable sweating”.

https://stevenfweinermd.wordpress.com/2015/10/09/hyperhidrosis-of-face-body-and-axilla-can-be-treated-permanently-using-the-infini/

Does Radiofrequency, RF Microneedling, or Lasers Affect Hyaluronic Acid Fillers?

While there are number of studies suggesting that lasers and RF do not affect fillers, a recent article by Dr. Weiss opened up the debate again. In his paper he stated that biopsies showed evidence of heating around the filler. It did not evaluated the changes in the filler volume over time. He concluded that the filler was at risk to be affected by the heat. Dr. Davin Lim’s recently published study contradicts Dr. Weiss, and showed with RFM, there was no affect on fillers (biopsy proved) at multiple different energy levels.

The heat from RF Microneedling reaches approximately 65-75 C for 100 msec to up to 3-4 seconds depending on the device and parameters used. This is the “hottest” version of RF delivery used in aesthetics. This compares to the sterilization process of the fillers at the (Galderma) manufacturing plant of 110-120 C for 15-20 minutes.

Lasers can heat the tissue to a higher level, up to 100 C, but again, it is for milliseconds at best.

Conclusion: There should be no concern regarding placement of HA fillers with RF Microneedling or lasers, at any level of the dermis or subcutanous planes on the same day. Furthermore, there will be no effect on previously placed HA filler. As a side note, PMMA has to be heated to 160 C to cause changes to it’s structure. While the exact temperature is unknown for calcium hydroxyapatite, it is significantly higher than HA, so it too is safe from RF and lasers.

Why Subcision is Needed When Treating Acne Scars with Lasers or Radiofrequency (RF)

Acne scars are routinely treated with laser and RF or RF microneedling. However, the optimal benefits are probably not achieved unless subcision is performed. Here’s why –

Acne scars frequently will have collagen scar fibers extending to the subcutaneous fat, fat pads, or fascial layers. These fibers cause tethering of the dermis, leading to the appearance of an atrophic scar.

FACT: RF and laser energy has a propensity to travel through collagen.

FACT: As energy/heat travels through collagen, it heats the collagen and leads to collagen contraction

Theory: When treating tethered scars, there is a possibility that the collagen contracts and actually makes the atrophic scars appear deeper

Theory: When energy/heat travels down the collagen fibers, some of it might be transferred to the surrounding fat and lead to fat atrophy.

Subcision is a process where the tethered collagen fibers are transected. By cutting these fibers, the energy can’t progress to the deeper layers of tissue and thus not cause possible fat atrophy or further deepening of the scars. I perform this on most patients undergoing laser or RF for acne scarring if I feel there is any degree of deeper scarring or tethering. There is also the benefit of subcision even without using energy based devices in improving acne scars.

2019 UPDATE: State-of-the-Art Acne Scar Treatments

Acne scarring has significant debilitating effects on one’s overall self-worth and confidence. Millions in the US are affected. There have been improvements in techniques and energy devices in past few years which have led to better outcomes for acne scar treatments.

Subcision – This is process of breaking up deeply tethered scar bands associated mainly with atrophic/rolling scars. Subcision has be performed for acne scars for decades and just using this procedure alone has proven to lead to significant acne scar improvements. Recently there have been a couple publications suggesting that cannula subcision had better outcomes, less downtime, and less discomfort than the traditional method of using a Nokor needle. A cannula has a blunt tip so it is also safer – less chance for cutting a nerve or blood vessel than the knife-like edge of the Nokor needle. In the study, both patients and the performing doctor rated the results better when using the cannula. Subcision is particularly important, in Dr. Weiner’s opinion, to be performed prior to any energy device for tethered scars. This is based on the fact that RF and laser will preferentially travel through collagen – which is high is water content – than fat or most other tissue. Scars are predominantly collagen, so it makes sense to cut the connection of the scar to the deeper tissue. Through personal communication with Dr. Davin Lim, biopsies he performed have shown scar band that reach the deeper fat pads from tethered acne scars. Transmission of the energy through the scar can theoretical lead to collagen contraction and deepening of the tethered scar. Sometimes fillers are placed at the time of the subcision to improve the volume loss associated with the scarring. Some hypothesize that putting a “spacer of filler” might improve results as well. Dilute lidocaine during the initial passes allows for this procedure to be well tolerated.

TCA CROSS – TCA (Trichloroacetic Acid) is a chemical peel used to improved acne scarring by placing minute quantities in the scar using a toothpick. CROSS stands for Chemical Reconstruction of Skin Scars. The most common use of this procedure is for ice pick and small boxcar scars. The process of causing a controlled chemical burn, allows for the body to heal from the deepest part of the scar towards the skin surface. This makes the scar smaller in diameter and shallower. Usually a series of 3-6 treatments are needed, with 3-4 weeks between treatments. There will be some mild scabbing for a few days which needs to be kept moistened for best results. Risk include widening of the scar or post inflammatory hyperpigmentation (PIH).

Radiofrequency Microneedling – This technology (RFM) has been available in the US for about 6 years and has revolutionized acne scar treatment. Using needles which are insulated, energy is delivered into the scar tissue directly and bypassing the epidermis, for the most part. The insulation protects the skin surface from heating so darker skin type individuals are at much less risk of PIH (post inflammatory hyperpigmentation) vs a laser treatment. The needles allow for deeper penetration than lasers as well. Overall, downtime is less than ablative lasers in most individuals (when insulated needles, proper technique, and appropriate settings are used). With acne scarring affecting darker skin types disproportionately, this is an excellent alternative to lasers. The Genius has recently been FDA approved and is now the “best of bread” RF microneedling device. There is now impedance feedback from the needles which allows for improved and exact energy delivery. The resistance in the tissues being treated is measured and this is important because throughout one’s face, there are differences, as well as between different individuals. Also, as tissue are heated or subcised, the resistance changes. Prior to Genius, there was no idea of how much energy was being delivered. There is now an accurate total energy for each pulse and a cumulative total. Other improvements include needle design-sharper, stronger motor, and feedback regarding quality of each pulse fired.

There is a myth that needs to be busted. Deeper does not mean better for acne scars.

The needles must stay within the scar for best results. If the needles go beneath the dermis, there is a risk for heating the fat and fat loss. Let it be known that the actual depth of the needles in most RFM devices is less than the settings, and becomes less accurate, the deeper the settings are. There is inherent resistance of the skin to penetration and many needles aren’t sharp enough or motors aren’t strong enough to get to the desired levels in the time required. This has also been addressed with the Genius and it’s depths are very accurate after extensive testing.

In addition, higher energy levels on any device which doesn’t monitor impedance, can actually result in very little energy delivered. Once the tissue is heating beyond a critical level, the resistance becomes so high that energy output cuts off. However, when higher energy levels are desired when using the Genius, the energy is adjusted to the increasing impedance and it is successfully delivered.

Fillers – Fillers are a very integral part of improving acne scars. They are extremely useful for the atrophic scars and the lipoatrophy associated with these scars. The aging process leads to dermal thinning and fat atrophy, which makes the acne scars appear worse, even if active acne has long been controlled. Fillers need to be injected deeply for correcting large areas of volume loss and superficially in minute quantities for focal defects. A hyaluronic acid filler will give about 12 months of improvement vs Bellafill which can give near permanent improvements. Bellafill does require a skin test to see if one has a allergy to the bovine collagen (0.5% chance) which needs 3-4 weeks to determine. There is some who feel fillers in areas of subcision will prevent re-adhesion of the scars. Most failures from other treatments are related to not recognizing the need to fillers to improve the acne scars.

Lasers – Erbium/CO2 ablative lasers still are beneficial for acne scars but have more downtime and risks vs RFM. Deeper skin imperfections are not improved with lasers and require fillers. These devices are best reserved for more superficial scars, mainly boxcar scars. Non ablative lasers are less affective but safer and in the author’s opinion give very minor results.

Microneedling – Also know as “Collagen Induction Therapy” CIT, has become popular in recent years. There are rollers available for home use and then there are medical grade devices which go to depths of 2mm or deeper and create thousands of penetrations per second. Rollers should be not be used at home for 2 reasons – questionable sterility at home and they tear tissue more than the in-office devices. Often these treatments are combined with topicals and PRP. It is highly recommended to not use any products on the skin which would normal not be injected. There have been many cases of infection and granulomas from these practices. Even when done in the office with PRP or amniotic membrane products, the efficacy of this procedure is minimal, and should be reserved for only mild acne scarring.

PRP/Amniotic membrane products – There is some date to support that better results and faster recovery with less side effects if PRP or amniotic membrane products are used during acne scar treatments. There is a movement more towards amniotic/placental products and away from PRP because there are more growth factors/healing properties in these vs PRP.

LLLT – There is a plethora of studies to suggest that using low level laser light (LLLT) is beneficial to results and healing times. The most researched device is Healite, and this should be performed immediately following all acne scar procedures which use energy devices. It calms the skin and improves circulation.

Acne scarring procedures are continuing to improve as technology and techniques evolve. One must understand that results require months to fully appreciate and multiple treatments (3-5 or more) are often needed to optimize results. Expectations need to discussed with providers/patients so that all are on the same page as to what one can achieve with treatments.

Dr. Weiner is an Acne Scar Center of Excellence designated by Bellafill and is a specialist on acne scars. He is a lecturer and trainer for Bellafill. He has become one of the leading authorities on Radiofrequency Microneedling and travels the globe lecturing on this technology. He performed the FDA trails for the Genius. He recently authored a chapter on RF Microneedling which soon will be published in the Facial Plastic Clinics of North America. He also wrote a recent chapter on Radiofrequency Safety and Complications which will be part of a book titled “Complications in Minimally Invasive Facial Rejuvenation: Avoidance and Management” by Paul Carniol, MD

The Genius is Truly a Huge Step Forward for RF Microneedling

The initial studies of radiofrequency microneedling (RFM) were performed by Hantash et al. in 2009. What Hantash was able to demonstrate was that RFM produced a fractionated radiofrequency thermal zone (RTZ) with coagulated tissue surrounded by normal tissue. Overtime, multiple growth factors and inflammatory components led to complete replacement of the RTZ with neocollagenesis and neoelastogenesis over the following 10 weeks.

Delivery of the RFM energy varies according to the device used. Unfortunately, there has been a paucity of solid research behind the majority of the devices. There is confusion in the marketplace for both consumers and providers as to what constitutes the best delivery system for outcomes, safety, and comfort. Lutronic decided to breakdown all the components of RFM energy delivery and optimize them in their development of the Genius.

One of the selling points of many of the devices has been that they are comfortable and have minimal downtime. What this actually means is that there is minimal energy delivered to the dermis. Discomfort is directly related to the amount of energy delivered. Lutronic’s research has shown that needle depths and energy settings don’t necessarily correlate to the what really occurs in the tissues.

Needle Depths

Skin intrinsically resists puncture by outside forces. If is especially difficult for 49 needles to penetrate the skin in a small area (1x1cm2). The natural tendency is for the skin to buckle with the needles “bouncing off the surface” and several of the RFM devices tested have been documented to exhibit this phenomenon. Furthermore, needles have a harder time penetrating deeper into tissue than superficially, so deeper depths are even more challenging to accurately place than more shallow treatments. Unfortunately, setting needle depth on the device doesn’t always correlate to actual tissue depth. Requirements for accurate depths include:

Sharp needles – but not too thin as to bend or dull during hundreds of pulses
Powerful motor – underpowered motors prevent accurate penetration
Quick motor – slower motors will lead to pushing the skin rather than penetrate it

Energy Delivery

One of the fallacies of RFM devices is that higher treatment levels correspond to higher energy delivery. Best results will be related to turning the energy settings “all the way up” is ABSOLUTELY FALSE. Too much energy in too short a period will lead to rapid rises in tissue impedance (resistance) and cut off energy flow immediately. Performance by the operator can affect the energy delivered if handpiece pressure is light or not flush with the skin as well.

Tissue Impedance

Impedance in the dermis is highly variable between patients and even within different areas of the face and body. Variables affecting impedance are: hydration, solar damage, collagen and hyaluronic acid content, and scarring. Using settings based on clinical findings and desired outcomes is not enough precision for optimal energy delivery.

Coated vs Uncoated Needles

Coated (insulated) needles allow the microneedles to penetrate the skin and deliver energy to the dermis while bypassing the heating of the epidermis. Some devices will use uncoated needles which will increase the risk of post inflammatory hyperpigmentation (PIH), particularly in darker skin types. To minimize this risk, uncoated needles use low energies and therefore sacrifice results. There will also be more downtime/wound care with uncoated needles because the skin surface will be more affected than with the coated needles.

The Genius Advantage

Proprietary needle design – sharp and coated for minimal resistance to insertion
Improved motor insertion – high torque and quick needle insertion
Improved protocols – changes to energy and pulse durations to avoid sharp rises in impedance based on Lutronic proprietary research
Impedance Feedback – the needles monitor tissue impedance every 2 msec and give feedback to the device to optimize energy delivery and adjust flow as resistance changes. This is the “brains” of the Genius.
Energy delivered feedback – each pulse is monitored and amount of energy delivered is noted. If energy is not exactly as desired/set, both a visual and audible signal is sent to operator. Adjustments in settings or technique can be made to improve energy output.
Total Treatment Energy – a running total of energy given is kept. This allows the provider to base treatments on energy delivered. Cumulative energies delivered from multiple treatments will become the standard of care to achieve clinical outcomes for a given diagnosis.

With the advancements made with the Genius, suddenly, all other RFM devices are now obsolete. Genius delivers a precise, safe, and efficacious treatment for laxity, wrinkles, neck lines, acne scarring, and hyperhidrosis in all skin types.