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Original Article

Radiofrequency: Review of Literature

Metin Görgü, Ali Gökkaya, Jehat Kizilkan, Ertugrul Karanfil, Ali Dogan
Department of Plastic Reconstructive Surgery, Abant Izzet Baysal University, Bolu, Turkey

Abstract
Background: Radiofrequency (RF) devices have widespread use in skin rejuvenation. Although they are used noninvasively, recently minimally
invasive RF devices are being added to the inventory to increase their efficiency. Because RF devices do not operate on a light basis, their effects
are independent of skin color and type. Therefore, they have a broader spectrum of patients compared to other noninvasive and minimally
invasive devices. Skin rejuvenation with RF devices will continue to be important for plastic surgeons to pursue the nonsurgical operations.
With RF application, heat is generated at different levels and different degrees under the skin. Methods: Shrinkage and denaturation of the
collagen with temperature increase the likelihood of desired rejuvenation effects. The degree of temperature increase in RF applications
depends on the frequency of the devices, the power of the devices used, and the characteristics of the headers. Today, different types of RF
devices are offered by manufacturers. Heating with an RF device in a therapeutic dose of the skin is possible if appropriate frequency and
adequate power are provided. When the therapeutic temperature is close to the complication limit, the user needs to know the device well, be
aware of the skin structure at the application site and skin thickness, as well as can adjust the application doses well to get better therapeutic
results. Conclusion: The wide variety of RF devices has led to the development of different application methods for users. In this article, RF
devices, mechanisms of action, methods of use, clinical practice techniques, and results are reviewed. Even though the results are good, RF
applications are not an alternative to a surgery.

Keywords: Laxity, noninvasive, radiofrequency, skin tightening, wrinkle

Introduction However, there is no other minimally invasive or noninvasive

method other than Botox, reaching the satisfactory results as
Skin rejuvenation and fat loss constitute a significant part
the surgical outcomes.
of plastic surgery’s aesthetic operations. While facelifts for
facial rejuvenation, blepharoplasty operations, liposuction, Radiofrequency (RF) is an important method among ablative,
and contour restoration are performed using plastic surgery noninvasive, and minimally invasive methods used for
techniques, nonsurgical patients and nonsurgical physicians rejuvenation, regional fat loss, and contour restoration. Because
and aestheticians focus on noninvasive and minimally invasive it can be applied to all kinds of skin types, RF has been adopted
methods. Noninvasive and minimally invasive  (in some from the beginning and gained popularity in this field. With
societies, so‑called medical aesthetics) methods have reached the widespread use of RF, various RF devices have emerged;
an ever‑growing economic dimension with increasing demand different application techniques are being defined and continue
due to the introduction of various devices and products to the to be developed.
market. Manufacturers, marketers, users, and practitioners who
want to increase their share in the aesthetic market sometimes Radiofrequency Technology and Devices
claim that the results are comparable to the surgical operations.
Previously, RF was initially used for cauterization purposes.
However, it is not possible to obtain a result that is comparable
to surgeries. There are a couple of exceptions; one of them is
Botox practice. It is frequently used for the rejuvenation of the Address for correspondence: Prof. Metin Görgü,
upper face and, nowadays, has greatly reduced the requirement Deaprtment of Plastic Reconstructive and Aesthetic Surgery,
of aesthetic surgery operations including the lifting up of Abant Izzet Baysal University, Bolu, TR 14280, Turkey.
E‑mail: [email protected]
forehead and brow, even though the results are temporary.

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DOI:
10.4103/tjps.tjps_65_18 How to cite this article: Görgü M, Gökkaya A, Kizilkan J, Karanfil E, Dogan A.
Radiofrequency: Review of literature. Turk J Plast Surg 2019;27:62-72.

62 © 2019 Turkish Journal of Plastic Surgery | Published by Wolters Kluwer - Medknow

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Görgü, et al.: Radiofrequency

In 2002, ThermaCool (SoltaMedical, Inc., formerly Thermage, Noninvasive heads can be monopolar (with grounding used,
Hayward, CA, USA) started using a 6‑MHz frequency device heads without grounding are called unipolar heads), bipolar,
for the treatment of skin tightening and facial wrinkles multipolar, and fractional. Minimal invasive headers include
following the Food and Drug Administration approval.[1‑9] fractional (with microneedle heads insulated or noninsulated)
Initially, noninvasive lasers and light sources were used for skin and subcutaneous probes.
tightening, wrinkle reduction, and skin rejuvenation. However,
The monopolar head is usually used in conjunction with a
with the ability of RF devices that can be used in all types of
grounding located in the right arm, and in practice, the current
skin, they have reached a common use over time.[1,2,9‑11] As it
is directed from the monopolar head to the ground that turns the
becomes popular in the market, different RF devices are being
tissue resistance to heat in order to obtain the deepest effect.
developed with a combination of many techniques. Due to the
In this way, the depth control can also be estimated. Bipolar,
high demand for rapid, noninvasive and minimally invasive
tripolar, or multipolar heads have + and − poles on the same
skin rejuvenation techniques, nowadays, various devices are
head. For this reason, no grounding is required. The current
being manufactured and techniques are being introduced.[1,2,9]
flows between two poles of the head and the depth at which
RF technology includes any electromagnetic wave frequencies the current reaches is assumed to be half of distance between
within the range of 3 KHz to 300 MHz.[7] An RF field is two electrodes.[12,14] However, it should be noted that the depth
composed of both electrical and magnetic components. The will also vary with different frequencies. When the RF energy
frequency range of RF devices used in skin rejuvenation ranges is transferred from the monopolar head as electromagnetic
from approximately 0.5–40 MHz. The frequency of RF device radiation rather than as a current, the obtained dielectric heating
is important, and it is inversely proportional to the depth of is rather resistive heating, so no grounding is required, and it
penetration. It is known that the lower frequencies have higher is called unipolar RF.[15]
penetration rates.[12] For instance, the penetration depth of 40
Fractional minimally invasive RF devices may be divided
MHz frequency will remain superficial compared to that of a
as bipolar or multipolar and electrode fractional RF or
frequency of 1 MHz.
microneedle fractional RF. [15] In fractional RF, multiple
The tissues have a resistance against electrical currents electrode arrays  (pins) or paired microneedles are used for
(impedance) and this resistance creates heat; therefore, the RF heating the tissue. There are some untreated areas left to help
penetration depth is calculated by tissue impedance and RF accelerating wound healing and maintaining skin integrity.[9,16]
frequency. Energy (J) = I2 × R × T (I: Current, R: Impedance, Different histologic patterns of fractional injury may be
t: Time/seconds).[1,2,6,7] As can be seen with formula, the heat produced by using noninsulated or insulated needles. While
that will emerge is directly related to the power of the electrical the use of noninsulated needle creates fractionalize damage
current and the tissue resistance. As a result, the same result to the epidermis, insulated needles only heat an area of the
in different areas and different individuals with the same RF sphere at the tip of the needle, protecting the epidermis and
current cannot be obtained. Different tissues will have different the dermoepidermal junction.
resistances, and similar tissues will have different resistances in
In subdermal or subsurface minimally invasive RF devices
different individuals. Therefore, either of the target temperature
(ThermiTight; ThermiAesthetics, Southlake, TX, USA),
should be monitored, or the practitioner must have enough
subdermal heating temperature is measured using a thermistor
experience to achieve adequate heating.
attached to the tip of the subdermal internal probe (55-65 C
The electrical conductivity of each tissue is different.[3] Electrical for dermis, 70°C for fat), while the surface temperature is
conductivity is elevated in regions with high blood circulation. measured using a thermal imager (42°C–45°C) and thus a
The bone has a poor electrical conductivity. Thickness of the controlled heating can be provided.[16,17‑19] The subdermal probe
dermal layer in patients may also vary at different anatomical can be placed directly into the RF target tissue invasively to the
sites  (2–5  mm). Likewise, skin properties, such as having desired depth, and the nerves mapped with the nerve stimulator
cellulites, require deeper heating of the subcutaneous layers. can be provided with a temporary Botox effect by heating at
Conversely, other conditions, such as rhytids, require reduced 85°C for 1 min.[17,18,20]
heating of the dermis layer.[12] High‑impedance tissues, such
In RF applications, combining variables  (frequency,
as subcutaneous fat, generate greater heat and account for the
current duration, tissue resistance, head type, noninvasive
deeper thermal effects of RF devices.[6,13] The heat generated by
usage, etc.,) with other technologies have resulted in a broad
the RF will depend on the resistance of the tissue to the electrical
variety of different RF devices. Thermage/Thermacool is
current. Therefore, in different tissues, heat will form at different
the first RF device for the treatment of wrinkles and has a
degrees and different depths. For this reason, it is more likely
frequency of about 6 Mhz. Thermage/Thermacool warms
to obtain nonreliable results. Therefore, the procedure must be
deep tissues with a monopolar head under computer control.
done on the same tissue by the same person.
The Thermage CPT system  (Solta Medical, Hayward,
California, USA) is a vibration setting incorporated with a
Device Heads handpiece of monopolar RF[8] [Figure 1]. The system has a
The RF stream is transmitted to tissue by a header. digitally pulsed cryogen spray unit which enables precooling,

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Görgü, et al.: Radiofrequency

parallel cooling, and postcooling of the epidermis.[8] The such as infrared  (IR) light, vacuum, mechanical massage,
monopolar RF Trusculpt (Cutera) has its own large electrode cooling, light‑emitting diode, and high‑intensity focused and
RF current reaching to 7–15‑mm deep and providing heat micro‑focused ultrasound are being combined with RF to
for fat apoptosis, thus aiming for fat reduction.[20] EndyMed increase synergistic interaction to improve skin rejuvenation
Intensif applicator (EndyMed Ltd., Caesarea, Israel) uses an and tightening effect.[1,2,18,24]
array of 25 noninsulated gold‑plated microneedle electrodes
with a maximum penetration depth of 3.5  mm.[21,22] Exilis Named Technologies and Trademarks (™)
system  (BTL Aesthetics, Prague, Czech Republic) and
Manufacturers name the technologies and even the applications
Pelleve  (Ellman International, Inc., Oceanside, NY, USA)
heads as TM. For example, Tune Face™ is a cooled,
use a continuous motion technique to deliver RF energy to
vacuum‑assisted unipolar, 40.68‑MHZ, 6‑pin, fractional
the skin[20] [Figure 2]. Today, there are various devices that the
RF applicator, used for the face.[15] Similar to the heads,
frequencies can be adjusted. VR52 (VCA laser, Beijing, China)
also, some devices are found on the market in the market
uses 1–40 MHz adjustable RF energy with monopolar, bipolar,
with popular names that summarize the method. Examples
and tripolar face (small) and body (large) heads [Figure 3].
include channeling optimized RF energy  (CORE); [12]
INFINITM (Lutronic Corp., Goyang, South Korea), is a High
electrooptical synergy  (ELOS); [6,25] switching, vacuum,
Intensity Focused RF system which has 1 MHz RF, with bipolar
and cooling  (SVC); and functional aspiration controlled
array of insulated microneedles (7x7/1 cm2) that are embodied
electrothermal stimulation  (FACES).[26] The practitioner
in a single-use disposable tip [Figure 4]. Because the shaft of
should examine these types of technologies and know what
the needle is insulated, there is no electrothermal damage to
they mean. While special names can sometimes emphasize a
the epidermis and the dermoepidermal junction. Therefore,
significant technological difference, they sometimes aim to
epidermal cooling is not needed.[23]
increase commercial popularity.
Different heads can be used for a single device and can be
In SVC technology, the device controls the RF energy
combined with other technologies. Different techniques
penetration depth as a shallow, medium, and deep by controlled
sequence of paired electrodes at different distances in a
fractional RF handpiece.[27] The switching process converts
between three RF frequencies, providing superficial moderate

Figure 2: Pelleve radiofrequency machine and radiofrequency body head:

Photos are from Ellman website (URL: http://ellman.com/index.html,
http://ellman.com/pellefirm‑system.html)
Figure 1: The Thermage system (the photos are from Thermage internet
web. URL: https://www.thermage.com/hcp#the‑thermage‑system)

Figure 4:  7 × 7 microneedle head of INFINITIM radiofrequency Device:

Photo is from Luthronic website (URL: https://int.aesthetic.lutronic.com/
Figure 3: VR52 radiofrequency Machine intl/products/infini/)

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Görgü, et al.: Radiofrequency

and profound effect.[27] CORE technology is applied by and dermal results of noninvasive heating with a 1‑MHz
combining three different frequencies (0.8, 1.7, and 2.45 MHz) four‑electrode system with RF.[30] VelaShape III  (Syneron
with vacuum and massage [Figure 5]. In Viora (Reaction™; and Candela) combines optical energy with bipolar RF, using
Viora Inc., Jersey City, NJ, USA), SVC is combined with pulsed suction and mechanical massage for deeper penetration
CORE technology.[12] ELOS combines light devices such and heating the tissue.[28] eMatrix (Syneron‑Candela, Irvine,
as bipolar RF and diode laser and IPL[25] [Figure 6]. FACES CA, USA) is a minimally ablative fractional bipolar RF which
use negative pressure to suction skin into a bipolar RF head, uses an array of paired microneedles to get rejuvenation with
and gel or liquid applied on the skin to protect the epidermis low epidermal disruption and high dermal remodeling.[24,28,31]
(Aluma‑System, Lumenis Inc., Santa Clara, California, USA). Venus Freeze (Venus Concept, Toronto, Canada) is a multipolar
[24,26]
Polaris(900 nm diode laser combined with bipolar RF, RF, which uses pulsed electromagnetic field that stimulates
Syneron Israel) and Aurora (IPL combined with bipolar RF fibroblast proliferation, angiogenesis, and collagen synthesis
Syneron Israel),[26,28] now Elos‑plus (Syneron‑Candela Israel) in a nonthermal manner.[28,31] EndyMed PRO™ 3 (Endymed
are devices with ELOS technology which is combining light medical, Caesarea, Israel)  (3DEEPR) is a technology, using
with bipolar RF. The Accent System (Alma Lasers, Ltd., a multipolar RF with real‑time skin impedance readings,
Caesarea, Israel) is a RF system that uses two RF configured handpieces for facial and body sites[22,31‑33] [Figure  8]. It
handpieces on a single platform: unipolar, which permits is a multisource RF system platform which consists of
volumetric (deep), and bipolar, which does superficial tissue nonablative skin tightening, ablative fractional RF, and ablative
heating, it is now known as Accent Prime and has many different microneedles RF[33] [Figure 9]. Pelleve (Ellman International,
types of heads. [Figure 7].[29] Using RADIO4 (Via dei Guasti Inc., Oceanside, NY, USA) 4‑MHz monopolar RF system
29, 20826 Misinto, Milan, Italy), Nicoletti et al. histologically
demonstrated ex vivo and in vivo samples of epidermal

Figure 5: Channeling optimized radiofrequency energy technology: The Figure 6: Electro‑optical synergy technology: The photo is from
photos are from Viora website. URL: https://www.vioramed.com/en/ Candela‑Syneron Web site (URL: https://syneron‑candela.com/na/
technologies/core‑technology technology/elos‑technology)

Figure 7: Accent prime: The photo is from Alma Lasers Web site (URL: Figure 8: Endymed radiofrequency machine: Photo is from website of
https://www.almalasers.com/alma‑products/accent‑prime/) Endymed (URL: http://www.endymed.com/)

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Görgü, et al.: Radiofrequency

of collagen and allow the collagen and elastic fibers to shrink.

As a result, the skin becomes thicker, firmer, and more tense.[12]
In RF applications, the temperature of the same tissue varies
depending on the depth of the tissue, the frequency, the power
of the devices, the types of the head, the maximum temperature
reached, the heat exposure time, and tissue hydration as well
as tissue type and age.
Collagen is composed of triple helix of proteins connected by
interchain hydrogen bonds. When collagen is heated with RF,
the bonds are affected, triple helix degrades, collagen part is
denatured and contracted.[9] The tissue is burnt as a result of
overheating. Ideal shrinkage temperatures range from 57°C
to 61°C,[9] but the time of the heat applied is important as
well. The effect of mechanical stress on fibroblasts stimulates
Figure 9: Radiofrequency mıcroneedle handpıece: Photo is from website extracellular matrix remodeling, which occurs after the
of Endymed (URL: http://www.endymed.com/site/products.php) contraction phase of wound healing.[12] It has been shown that
mechanical stretching causes an increase in Type I and Type III
with multiple‑size tips provides continuous motion and collagen expression,[12] demonstrating that mechanical stress
surgical electrocautery capability.[24,30] ePrime (Syneron) is a alone can also act on collagen and skin without heat effects.
microneedle bipolar RF.[31] There are also some personal‑use
RF devices.[34‑36] Fibrous septa: Heating deeper tissue disrupts fibrous septa,
and the result is three‑dimensional tissue contracture. With
the shrinkage and contracture of the fibrous septa between
Where Do We Use Radiofrequency the subdermal fat tissues, there is not only a tightening in the
Using RF devices, skin wrinkles and various skin conditions horizontal plane of the skin but also a shortening in the vertical
can be treated, including periorbital rhytids, lower cheek jowl, plane (Z‑dimension).
nasolabial folds, marionette lines, lower lid tightening, brow
lifting, atrophic scaring, acne and acne scarring, cheek laxity, Capillary blood flow and adipocytes: RF heating increases
neck rejuvenation, and axillary hyperhidrosis.[37] Over time, local capillary blood flow which increases adipocyte
RF usage areas are expanding. Fistonić et al. used monopolar metabolism. Moreover, nonthermal effects of RF include
focused noninvasive 3.25‑MHz RF device for labia tissue adipocyte stimulation, leading to lipase‑mediated degradation
tightening.[38] Key and Boudreaux and Biesman and Pope used of triglycerides or even adipocyte apoptosis.[9] The heating
RF on eyelid rejuvenation (by protecting eye with a plastic effect increases microcirculation, homogenizes subdermal
ocular shield).[5,39] Pongsrihadulchai et al. used nanofractional fat, and increases skin elasticity.[12] Thermal exposure at 43°C
RF device for striae alba.[40] For posterior upper arm skin laxity, for 10 min results in a delayed adipocyte cellular death,[12,20]
a subdermal thermistor‑controlled monopolar RF was used.[19] and thermal exposure at 45°C for 3 min results in a loss of
cell viability in 60% of adipocytes. In vivo fat cell lipolysis is
Ideally, the patient group will consist of individuals with enhanced by increased delivery of catecholamine hormones,
mild, moderate laxity, mild lines, and wrinkles between 35 which is improved by enhancement of blood flow.[12]
and 60  years of age. For severe laxity and deep wrinkles,
invasive surgical methods, such as face/neck lifting, should be Fibrous septa contract to inward as deeper effect of RF.[9] RF
considered. Anticipation of the patient is important, and it is stimulates neocollagenesis, elastin, and ground substance
necessary not to apply RF to the patient who can get successful production, which results in delayed dermal tightening and
results only by invasive surgeries. contour changes.[9]
Immediate posttreatment biopsies after RF do not give much
Mechanism of Radiofrequency Treatment evidence. However, perivascular and perifollicular infiltrates
can be seen after a few weeks, and a similar amount of
RF induce tissue tightening and contour changes through
shortening and shrinkage in collagen fibers is shown in electron
dermal collagen remodeling without disruption of the overlying
microscopic evaluation.
epidermis as a noninvasive procedure with a short recovery
period and small risk of adverse effects.[1,2,6,10,11] The RF current, like SIRT6, upregulates Sirtuin genes while
downregulating SIRT1, 3, 5, and 7, resulting in new collagen
RF produces heat deep in the dermis due to tissue electrical
formation and increased fibroblast survival.[28]
resistance.[1] With RF application, different levels and different
degrees of heat are produced under the skin. The heat increases An electromagnetic field from which the RF current is
collagen denaturation that results in shrinkage and the desired generated has thermal and nonthermal effects.[13] For the
rejuvenation effect. The RF effect is achieved by heating the thermal effect, almost everyone agrees that there is a collagen
fibroblasts to such an extent that they stimulate the production contraction and shrinkage of collagen as well as the stimulation

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Görgü, et al.: Radiofrequency

of collagen synthesis.[13] Nonthermal biologic effects occur be generated in the dermis. 55°C–65°C is considered to be
in cell membrane receptors and channels, which induce sufficient for the clinical effect. It is not possible to measure
cytoprotective growth factor synthesis, heat shock genes, the heat formed in the dermis, except using an invasive RF with
synthesis of mucopolysaccharide and elastic fibers (improve a subdermal probe during in vivo application for experimental
firmness and elasticity of skin), increase enzyme activity, investigations. Sufficient results cannot be obtained with
transcription of specific genes, mRNA expression.[13] suboptimal heat. For this reason, the patient’s response to
exposure to heat, the observation of changes in the skin, and
As the skin tensioning and tightening effect takes place at a
the experience of the doctor are important.
depth of about 5 mm, monopolar and low frequencies may be
required when an effect of vertical effect in fibrous septa and
fatty tissue is desired. Histopathology
RF application results have been evaluated histopathologically
Temperature of Radiofrequency Heating in many in vivo and ex vivo studies. In addition to the immediate
effects achieved by RF, there are fibroblast, adipocyte
RF heats dermis[1‑7,10,11,17,41‑44] up to a point to obtain therapeutic stimulation, and increased capillary circulation and delayed
effect without damaging the surrounding tissues. It is important effects. Hence, homogenization of histopathological changes
to keep the temperature below 45°C for epidermal (surface) heat is difficult and changes occur after hours, days, and weeks
treatment of the skin when aiming 3–6‑mm deep dermis heat at in the tissues following an application. In Belenky’s study,
around 65°C in the RF applications.[9] Fibroblasts are thought the subcutaneous tissue sample was discontinued due to a
to be stimulated for the production of collagen when heated microtrauma that happened 8 h following RF on pork skin,
at 55°C–65°C.[29] Subdermal probe measurements showed and the new connective tissue formation showed that healing
that collagen remodeling at 42°C–46°C, septal tightening at process was visible.[12]
55°C–65°C, lipolysis, liposculpting at 65°C–70°C, and nerve
damage at 85°C can be obtained.[18] Elman et al. suggested that Alvarez et  al. showed histopathological changes including
skin temperatures must reach 50°C, for skin collagen formation partial detachment of the stratum corneum, follicular dilation,
and cell proliferation. However, for skin tightening and lifting arrangement of melanin pigment in irregular clusters, irregular
effects, the dermis should be heated up to 40°C–50°C.[27] areas of epidermal hyperplasia, congestion and dilation of the
dermal blood vessels, dermal edema, and increased dermal
Sufficient heating in the tissues depends on electrical current, thickness in series of biopsies after RF application.[45]
duration, and tissue resistance. Tissue resistance differs
significantly between the patient and the treatment area.[3] Immediate heating results in collagen denaturation with a
Lack et al. pointed out that the highest level of impedance resultant fibrous contraction and tissue thickening determined
occurs at arms, then the forehead, cheeks, and back.[3] by transmission electron microscopy studies.[46]

Although minimally invasive RF devices are considered to

be more effective and controlled in heating dermis without
Evaluating the Results of Radiofrequency
damaging the surrounding area, aesthetic patients are easier Treatments
to adapt to noninvasive methods and their demands toward Clinical observation and patient feedback are more widely used
this are increasing. in assessing RF outcomes, rather than limited histopathological
The use of RF emphasizes the importance of heating the dermis changes. Pritzker et al.[31] draw attention to the inadequacies
up to 65°C–75°C in the literature, while the temperature of the between the techniques used in skin rejuvenation, and
epidermis should not exceed 42°C–45°C. It is not possible to even the comparative evaluation of technologies, as well
measure the temperature of the dermis noninvasively, although as the differences in assessment standards and subjectivity.
it is possible to measure the temperature in the epidermis with Radiologic and ultrasonic measurements of tissue thickness
IR cameras. Minimally invasive RF devices are important for and histopathological findings support the effectiveness of RF,
this reason. Their aim is to heat the desired point to create a but it is not possible to evaluate the RF results objectively.
Subjective assessments are based on the visual interpretation
heat at the exact target point. Minimally invasive devices that
of doctors, observers, and participants. Different Classification
measure temperature in both superficial and subdermal tissues
Systems such as the Fitzpatrick Wrinkle classification,[1] the
were developed, and such devices can directly measure the
Lael laxity classification system, and the Alexiades laxity
temperature of the application area with a thermistor located
scale[1,4,7] are used in this assessment because the results are
at the tip of the internal probe, while epidermal temperatures
hard to standardize. Measurements are made to the standard
are measured directly with an IR camera system. This type
with the help of some devices; the physical measuring
of dual system provides temperature‑controlled dermal and
device  (BTC‑2000, SRLI Technologies, Nashville, TN,
subdermal tissue therapeutic thresholds necessary for collagen
USA) measures both elasticity and skin stiffness.[44] Likewise,
remodeling.[16]
Wakade et al. used ultrabiomicroscopic sonography to measure
Dermis needs to be heated to achieve a clinical effect with RF, decrease in subepidermal low‑echogenic band of the nasolabial
although there are different opinions about how much heat will folds after RF and glycolic acid peeling treatments.[47]

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Görgü, et al.: Radiofrequency

How to Use Radiofrequency passes will seem relatively safe, but it will be exhausting and
will require a longer time. It may not be homogeneous to reach
It is aimed to heat the target with RF application, the target
therapeutic degree with heat accumulation. With a high‑energy
is often dermis and collagen at the region and the treatment
low pass, it is possible to achieve a shorter treatment time
area may also contain fibrous septa, fat tissue, and nerves in
and more homogenous therapeutic doses with increased risk.
the subcutaneous tissue. The epidermis needs to be protected
Epidermal cooling and moniterization of epidermal heating
during dermal heating. Keeping the epidermal heating at
is important when high energy with fewer pass is used. The
39°C–42°C temperature range will be enough to protect the
duration of the application is important for the patient and the
tissue. How we provide this with the RF device depends on the
physician. Patients consider it as a lunch break application and
different devices and their characteristics. On some devices,
they want to complete the treatment as soon as possible. As
RF is applied to a field with a single touch, while in some
for physician’s perspective, time is very valuable, therefore
devices the RF header is circulated at the area. If the device
shortening treatment time by using high‑dose single‑pass
does not have a thermal meter to monitor the dermal heat, the
setting will be preferred, but we must remember applying high
effect is determined by the patient’s skin, and the reaction of
energy is risky. RF treatments are popularized with the slogan
the patient against the heat. In practice, it is useful to have a
of maximal results with minimal side effects,[4,44] Therefore
thermal camera in hand; now, thermal cameras are very small
multipass with lower energy option should be considered
and can be adapted to tablets and mobile phones.
because collagen denaturation with such settings can also be
During application, it may be necessary to change the power achieved effectively and safely. In this case, faster and/or wider
of the RF current, while more current is required in regions treatment headings will be required.
where the skin is thicker, and less current is required in regions
where the current is thinner. Aftercare
It is possible with gel application to protect the epidermis Patients do not experience downtime unless there is a
during RF application and allow the head of the device to complication after RF application. The patient immediately
slide easily in the treatment area. If the device does not have feels heat in the skin after treatment, a feeling that lasts for
its own cooling system, using a gel will be sufficient. Cold air 1–2  h, and almost every patient may have a few hours of
can also be applied for epidermal cooling. erythema and edema. After the process is completed, the use
No significant preparation is required before RF application, of cooling gel, ice pads, and cold air might help. Sometimes,
but skin cleansing is necessary. Dirt, oil, and makeup materials corticosteroid creams (only once just after RF for erythema)
that may affect the passage of electrical current must be can be supplemented with sunscreens. It is recommended to
removed. The application process is generally done from top use skin moisturizing creams afterward.
to bottom  (“Free‑hand”) sweeping  (“paint‑brush”) motion,
with horizontal strokes and vertical strokes alternating until Pain and Anesthesia
the set time expires. The heating that occurs during RF applications will naturally
Because RF is not a light‑based treatment, eye protection be sensed by individuals. As the temperature rises, a feeling
is not necessary unless applied directly to the eyelids. It is of pain develops. Pain threshold varies significantly from
recommended to have wet gauze placement between teeth and patient to patient, and some patients barely tolerate pain. Pain
lip when working on the lips. When we apply RF to the eyelid, is described as a brief burning sensation that rapidly dissipates.
we need a plastic protector for the device and eyes. When Key The difference between the impedance of individuals shows
et al. applied RF for 6 min using a 10‑mm cap on the eyelids different pain complaint during the same energy and frequency
with ThermiSmooth (Thermi, Irving, Tex.), they used a plastic treatments. Therefore, pain sensation is an important indicator
eye shield for eye protection.[39] and determines the boundary between the effect and the burn
for the practitioner. For this reason, some practitioners do not
Skin tightening, edema development, pain, and erythema
use topical creams that reduce pain. Reducing the sensation
during application should be closely followed up to reduce the
of pain will lead to higher levels of heat, but it is important to
risk of complications and obtain. Dover et al. suggested that
remember that the outcome and the complication limit are close
for optimal energy selection, patient pain feeling feedback is
to each other, and that we do not alter the pain treatment area.
a valid method, and treating to a clinical endpoint of visible
The erythema that occurs during the application will help the
tightening with multiple passes at moderate energy settings
temperature of the skin surface to be measured by a thermal
provides substantial and consistent results.[44]
imager or simply with an IR/laser thermometer to achieve a
Application can be performed in varying numbers depending degree of protection and therapeutic temperature.
on device, treatment area, and frequency and electrical current
RF application can often be done only by cooling, but
used.
sometimes topical anaesthetic creams or block local anesthesia
High energy with fewer pass or low energy with multiple or sedation may be used. Infiltrative anesthesia is not preferred,
passes can be applied.[4,20,44] The low energy with multiple as edema may affect the depth of treatment. Kushikata et al.

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Görgü, et al.: Radiofrequency

showed that topical anesthesia did not reduce the pain in RF topical steroid use within the last 2 months, oral steroid use
application sufficiently, so that it could not be applied at higher within the last 12 months, RF therapy within the last year,
energy levels with topical anaesthetic use, but topical anesthesia atrophic states of the skin (e.g., chronic radiation dermatitis),
did not change RF activity at 3 months of follow‑up.[42] patients unrealistic expectations, chronic corticosteroids or
chronic nonsteroidal anti‑inflammatory medication usage,
Protection of Skin obese patients, patients with fluctuating weight, excessive
skin laxity and excess, poor skin quality (severe photodamage,
The devices measure the heat of the skin surface and can have
severe elastosis), poor general or mental health, therapy with
receivers to determine if the target temperature has reached.
dermabrasion, chemical peeling or laser skin resurfacing within
However, the heat on the surface may not be correlated with
the last year, therapy with microdermabrasion within the last
the heat at the deeper tissue. As the frequency of the RF
3 months, fat augmentation within the last 18 months, over
device decreases, the depth of heat increases. It is possible to
tattoo or synthetic fillers (silicone).
externally control the surface temperature using coupling fluid,
gel, cold air, or peltier. It is safe to use it in patients who have previously undergone
facelift, blepharoplasty, laser surgery Botox, or fillers. RF
Sessions treatment does not cause facial hair loss; therefore, male
patients can be treated with no fear to beard or mustache loss.
RF application can be done in one session or in many sessions.
The number of sessions and time may vary depending on England noted that there was no significant negative interaction
the device and protocols implemented by the clinicians. between RF and various soft‑tissue fillers (collagen, hyaluronic
Multiple‑use protocols vary from 4 to 8 sessions and intervals acid, calcium hydroxylapatite, polylactic acid, and injectable
vary from 1 week to 1 month.[4,10,11,23,29,45,48] Therefore, at first, liquid) and RF in a filler study using an animal model.[41]
users apply the device with the protocol recommended in the Alam et  al. reported that there was no significant negative
manual, but modify these protocols depending on the results interaction between soft‑tissue fillers  (hyaluronic acid and
they have received over time. As can be seen in the literature, calcium hydroxylapatite) and RF in a short term.[43]
we can say that there is no standard by looking at the diversity
of protocols, because of the differences in the characteristics Discussion
of the devices, racial differences (directly related to RF skin
Along with improvements in technology, the diversity of RF
resistance), and the level of education of practitioners.
devices is increasing, and new devices are introduced having
additional features. Our aim in RF applications is that the
Complications and Contraindications patient and the doctor find the results satisfactory without any
Among minor complications in the early period include harm to the patient. This end result will expand the market
abrasion, edema, erythema, blistering, blanching, bruising, share with extra features (such as ease of use, quick application,
crusting, oozing, and purpura, and they emerged as short operation time, the ability to use different frequencies and
early clinical manifestations, rather than complications. headings simultaneously, instantaneous temperature changes,
They are often handled without causing problems. We and combined technologies).
may place scabbing and ulcers among some more serious early The technological advancement is necessary to improve our
complications; other serious complications include atrophy, knowledge and experience, but encountering new devices
hyperpigmentation, scarring, textural change, white area, do not mean that we will give up using effective devices
tenderness, and Poison Ivy).[1] that currently we have. Noninvasive applications in RF
In some cases RF treatment is absolutely or relatively remain important. The main purpose of using noninvasive
contraindicated, and in some cases it is not recommended.[8,12] RF devices is to heat the dermis and fat tissue noninvasively.
At the same time, we need to pay attention to the case of For effective use of the devices and technology, a physician
anatomical structures. should evaluate the outcome and the risk interactions, and he
should understand the device, the skin and their relationship.
Contraindications of RF; pregnancy, electronic implants
While RF devices seem easy to use, it is necessary to heat
(pacemaker, heart pill e.g.,) cardiac insufficiency, active or
the skin sufficient enough without creating epidermal burns,
recent malignancy, on metal‑containing apparatus such as hip
as the experience of the physician increases, it can be used
prosthesis, fracture fixation, a history of recurrent herpes simplex
at the high end limit of the device to make the procedure as
(needs preventive antiviral therapy), immune suppression,
effective as possible. Inexperienced users will have to choose
active local or systemic infections, dermatologic and vascular
a more controlled device. The development of the device will
disorders, increased photosensitivity, collagen‑vascular
ensure that this heating is done specifically at the desired level
disease, heat‑excitable disease, hypertrophic scars, coagulation
without damaging the epidermis. Such devices will remove
disorders, wound healing disorders.
the learning curve and increase safety. Noninvasive methods
Relative contraindications of RF; diabetes, oral retinoid use cannot provide the same results as of invasive or minimally
within the last 6 months, topical retinoid use in the last 2 weeks, invasive methods. However, they are preferred by patients as

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Görgü, et al.: Radiofrequency

noninvasive, lunch time procedures, with no downtime and and hypothesized that noninsulated RF needles  (emit RF
less complications. through the whole length of the needle) are more effective
than insulated needles (emit RF only through the tip of the
Araújo et al. claimed that, in Brazil, in many RF devices, the
needle).[21]
power is fixed and that it is not possible to obtain the results
of international devices that use power at varying degrees.[13] We do not have a single device and system to ensure that
everything is perfectly implemented, easy‑to‑apply, and to
It is not easy to standardize studies related to RF. The variables
obtain very impressive results without any complications. We
are too much and it is difficult to control. The number of
are also faced with many devices that offer different uses of
new assertive devices are increasing, but in practice the end
the same system. It is not easy to make the right choice in this
point of devices and treatment results are determined by
complexity since it is not always possible to obtain sufficient
doctors and patients during application. It is considered that
and effective results with a single device. Therefore, expensive
in the studies done, RF applications are effective for varying
investments are inevitable for those working in the aesthetic
degrees in patient evaluations, such as face‑to‑face repetitions,
sector. In plastic surgery field, this is a little more difficult, as
independent evaluation by photographers, Fitzpatrick wrinkle
the surgeon knows that he/she can get much better results with
scale, measurement of changes in forehead height, and biopsies
operations, and it is not easy to believe that the result will be
taken[13] when subjective evaluation standards are used. The
achieved with this trait or to be satisfied with about 20%. For
use of inadequate devices or presence of inexperienced,
this reason, the use of dermatology seems to be more prevalent
uninformed practitioners leads to doubt for this method, which
in the use and operation of such devices.
is considered to be effective in practice. Because the frequency
of the end device, the power, and the tissue of the patient will Devices used in skin rejuvenation alone are not adequate
affect the impedance, it is necessary for the doctor to know to solve the problem, for example, HIFU and RF cannot
and analyze them to find the appropriate option. It will be rejuvenate epidermis, while light‑based devices cannot be
determined by the experience of the user how many sessions used with the same efficiency in each skin type. The use of
will be continued or only single session will be used. technologies together sometimes increases the efficiency and
sometimes can also bring risks together.
The RF should allow the dermis to heat up to around 65°C,
while the skin should remain at 40°C–42°C. However, how RF devices are constantly and rapidly changing, and it is
many minutes should the dermis remain at 65°C. Is it enough difficult for manufacturers to find the same device 2–3 years
to go out of 65°C for only 1 s? For collagen denaturation, both later. In literature reviews, we will not find a published device
the heat level and exposure time are important. It is shown that on a website of a consumer firm frequently, but we will
10% of the collagen fibers shrink after heating at 65°C for 10 encounter devices with more advanced and different names.
minutes and 60% shrinkage can be obtained after heating at
80°C for 1.5 minutes.[8] Conclusion
When using microneedle  (insulated or noninsulated) in RF devices heat the tissues at different depths depending on
minimally invasive RF applications, we clearly know at their properties. To obtain the effect, the heat to be generated
what level we apply the RF current to the skin. In this must be at levels that provide collagen denaturation. The user’s
minimally invasive method, the recovery is faster because knowledge and the level of experience are as important as
of the fractional‑based procedure, and when applied as a the device to be used to achieve satisfactory results. The user
microneedle, the skin also has a dermaroller‑like effect. should be familiar with the characteristics of the device and
The insulated needles create fractional heat damage in the know the properties of the human tissue and the RF physics.
dermis  (usually 300  µ deep) only when needle puncture Thermal cameras and IR/laser thermometers will also help.
trauma occurs without any heat effect on the epidermis and
It is possible to achieve an effective result with RF, but patient
epidermodermal compartment. While using noninsulated
and physician expectations should be realistic. RF applications
needles, heat injury also forms in the epidermis and
are safe if attention is paid to contraindications and the
epidermodermal compartments. Controlled damage caused
limits are not exceeded in practice. The complications that
by the application of the insulated needle can be simulated
occur are minor and transient. It is safer and more effective
by the damage generated by high‑focus ultrasonic  (HIFU). to apply using low‑energy multipass instead of high energy
Compared to light‑based systems, RF applications have the in practice.
advantage of being more deeply affected, especially when
there is less risk of hyperpigmentation. However, regeneration It is not possible to achieve a result with RF that is comparable
with fractional ablative laser epidermis provides effects such to the surgical operations.
as correction of texture. Gold et al. using EndyMed Intensive
Financial support and sponsorship
applicator  (EndyMed, Caessarea, Israel)  (an array of 25
Nil.
noninsulated gold‑plated microneedle electrodes) found that
3  months of follow‑up is more improvement than 1  month Conflicts of interest
of follow‑up in Fitzpatrick’s wrinkle and elastosis scale[21] There are no conflicts of interest.

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