R a d i o f req u e n c y

M i c ro n e e d l i n g
Overview of Technology, Advantages,
Differences in Devices, Studies, and
Indications
Steven F. Weiner, MD

KEYWORDS
 Radiofrequency  RF Microneedling  Fractional RF  Highintensity RF  Microneedling  Laxity
 Neck rejuvenation  Acne scarring

KEY POINTS
 RF skin rejuvenation is improved using RF microneedling devices. More aggressive treatments are
performed safely with minimal downtime than previous RF devices.
 Optimizing treatment parameters is essential for safety and efficacy.
 Multiple RFM studies support minimal risks even in dark skin types.
 RFM has been used to treat acne scarring successfully as well as skin laxity and hyperhidrosis.

HISTORY OF RADIOFREQUENCY TYPES OF RADIOFREQUENCY

The use of radiofrequency (RF) in medicine is ubiq- There are 2 different delivery mechanisms which
uitous and dates back over 75 years. Energy pro- RF uses: monopolar and bipolar.
duced from RF has been used for cautery of Monopolar RF: the energy flows from an active
tissues/vessels, tightening of pharyngeal tissues in electrode within the operator’s handpiece to a
sleep apnea, and to destroy tumors. RF is used to grounding pad (passive electrode) placed distally
ablate accessory conduction pathways in the heart on the patient’s body. Early RF devices (Therma-
to improve atrial fibrillation and other conditions. RF Cool) used monopolar RF, and it is still a popular
diathermy is used in occupational and physical ther- technology in current devices. Its advantage is
apy to apply heat to deeper tissues. The term that the energy can be deposited rather deeply
“radiofrequency” originates from the frequency of from a surface electrode-deep dermis and fibro-
the electricity used is similar to that of radio waves. septal network.
In 2002, ThermaCool became the first RF device Bipolar RF: the energy flows between 2 adjacent
approved for cosmetic use (periocular rhytids) electrodes, both contained within the operator’s
and, in 2004, it received approval for treatment handpiece. The depth of penetration (for the trans-
of facial wrinkles and rhytids. In 2006, off face epidermal devices) is postulated to approximate
use was approved. Dozens of RF devices have half the distance between the electrodes, although
since been approved for esthetic use with various this is not universally accepted.1 Higher energies
methods used to deliver the energy to the dermis can be delivered with bipolar than monopolar,
facialplastic.theclinics.com

and fibroseptal network in the subcutaneous fat. but the depths are less.

Disclosure Statement: Lutronic-Infini, Carestream-Pronox.

2050 West County Highway 30A, Suite 114, Santa Rosa Beach, FL 32459, USA
E-mail address: [email protected]

Facial Plast Surg Clin N Am 27 (2019) 291–303

https://doi.org/10.1016/j.fsc.2019.03.002
1064-7406/19/Ó 2019 Elsevier Inc. All rights reserved.
292 Weiner

RADIOFREQUENCY ENERGY DELIVERY fibroseptal network, and adnexa are all heated
simultaneously, albeit to different temperatures.
Radiofrequency creates oscillating electrical cur- Heat accumulation is longer, as dissipation is
rent (millions of cycles per second), causing vibra- slowed when an entire area is heated versus a
tion and collisions between charged molecules, “fractional heating” technique. Leaving unaffected
thus resulting in production of heat, as described tissue adjacent to treated areas creates more
by Belenky and colleagues2 Electrical energy is rapid healing and safer treatments for lasers and
converted to thermal energy as resistance in the tis- RF.
sue is met.3 Energy transfer is dictated by Ohm’s Transepidermal RF tissue tightening treatments
Law: energy (J) 5 I2  R  T (where I is the current, have an inherent limitation because energy is
R is the tissue impedance, and T is the time of appli- delivered through the skin surface and the
cation). Impendence depends on skin hydration, threshold to prevent epidermal burns is signifi-
electrolyte composition, collagen content, temper- cantly lower than the optimal temperature for neo-
ature, and other variables.4 Unlike lasers, which use collagenesis. Whereas there are mild benefits to
a photothermal energy (selective photothermoly- heating of the dermis to 45 C to 60 C to get partial
sis), RF energy is independent of pigmentation/ collagen denaturing, optimal results can be
skin type, and is strictly an electrothermal effect. achieved only when dermal temperatures reach
The RF devices used in esthetic procedures range 65 C to 70 C, when coagulation and collagen
from 0.3 to 10 MHz. Depth of penetration is denaturing occurs. At these levels, collagen
inversely proportional to frequency used.5 removal and replacement occurs.8,9 Biopsies
have shown no increases in fibroblast numbers
RADIOFREQUENCY: EARLY APPLICATIONS with lower energy levels (below coagulation tem-
AND DEFICIENCIES peratures), and only collagen thickening/contrac-
tion. In contrast, higher-energy levels have
The initial RF devices pushed energy through the shown to result in a hyperplastic response and in-
epidermis to the deeper layers using monopolar creases in cellularity during the wound healing
technology. However, the depth of the heating is response, which continued for 10 weeks or
not precise and there are cases of fat destruction longer.10 Attempts have been made to deliver
from inadvertent subdermal heating.6 There are higher temperatures to the dermis with the transe-
also limitations in the temperatures that the pidermal RF devices using small, high-energy
epidermis can handle to avoid complications (concentrated) handpieces, but these have led to
such as postinflammatory hyperpigmentation epidermal injuries11 (Fig. 1).
(PIH), blistering, and scarring. It has been noted
that maintaining the skin surface to temperatures WHY RADIOFREQUENCY MICRONEEDLING
below 42 C to 45 C is essential for safe RF treat- VERSUS LASERS
ments because the threshold for epidermal burn
is 44 C. The methods for which devices have In the early 1990s, ablative lasers were introduced
used to overcome epidermal heating problems and showed marked results in reversing the aging
have been superficial cooling and constant motion skin of the face. Unfortunately, these lasers had
of the handpiece. To cool the skin, cryogen spray prolonged downtime, and high complication
or a cooling plate is applied to the skin simulta- rates12 (persistent erythema, hypopigmentation,
neously with the energy pulse and leads to a infection, and scarring) and they fell out of favor
reverse temperature gradient––deeper tissues in the early 2000s. Nonablative lasers were intro-
achieving higher temperatures.7 duced with less downtime and risks, but results
By delivering energy through a constantly mov- did not match the ablative lasers and multiple
ing RF energy handpiece, the skin heating can be treatments were needed. Fractional technology
more gradual and safer. Temperature can be was introduced in the mid-2000s initially with non-
monitored either by sensors within the handpiece ablative lasers and later with ablative lasers. Abla-
or with an infrared camera. Treatment is either tive lasers came back in favor because the risks
paused or completed when the surface tempera- and downtime were reduced when healthy tissue
ture reaches 42 C to 45 C. The downside to this surrounding the ablated areas sped up
technique is that the provider can fatigue during healing.13,14
the treatment or during subsequent procedures Despite advances in lasers, there remains 2 de-
later in the day. Uniform heating might not be ficiencies. Because the heat affects the epidermis
achieved under these circumstances. and dermis with a temperature gradient highest at
Bulk heating occurs with these superficial RF the skin surface, darker skin types remain at risk
devices, which means the epidermis, dermis, for PIH. Measures to reduce PIH are pretreatment
 Radiofrequency Microneedling 293

Fig. 1. Heating patterns of various RF delivery devices. (Courtesy of Lutronic, Billerica, MA.)

and posttreatment hydroquinone, tretinoin, and delivered deeper than laser energy––3 mm or
skin cooling (during the procedure) but these do more with certain devices.
not eliminate the problem.14
The other problem with lasers has been neck INITIAL RADIOFREQUENCY MICRONEEDLING
rejuvenation. Owing to the lack of pilosebaceous STUDY AND FOLLOW-UP STUDY
units, neck healing after deep dermal laser treat-
ments is slowed and impaired. Complication rates The initial study of using RFM was performed by
of ablative laser treatments of the neck is higher Hantash and colleagues18 in 2009. Studies were
than facial procedures, even when using fractional performed on abdominal skin in 15 patients who
technology.15–17 were later to have abdominoplasty. A handpiece
Radiofrequency has become a viable option for with 5 paired insulated needles with temperature
skin rejuvenation and tightening. Using electro- monitoring, and interface feedback with surface
thermal energy versus photothermal energy with cooling was used. Results showed areas of
lasers, RF is not chromophore dependent and collagen denaturing, RF thermal zone (RTZ) sur-
therefore considered applicable for all skin types. rounded by areas of normal collagen. Adnexal
This does not equate to meaning that darker skin structures and adipose tissue was spared. No
types are free from risk. Radiofrequency offers lit- adverse effects were seen.
tle to no downtimes, which is desirable in the cur- A follow-up study by Hantash and colleagues19
rent environment of patients’ active lifestyles and in 2009 using a similar novel fractional micronee-
busy work schedules. Results from transepidermal dling RF device showed “A vigorous wound heal-
RF have been highly variable with mostly disap- ing response is initiated posttreatment, with a
pointing results. To further enhance dermal heat- progressive increase in inflammatory cell infiltra-
ing, RF microneedling (RFM) was developed. tion from day two through 10 weeks. HSP72 dimin-
RFM delivers the desired energy through pins/nee- ished after day 2 while HSP47 increased up to
dles that penetrate the skin to a predetermined 10 weeks. Increases in IL-1b, TNF-a, and MMP-
desired depth. With this technology, dermal heat- 13 while MMP-1, HSP72, HSP47, and TGF-b
ing was improved to the critical level of 65 C to levels increased by 2 days. We also observed a
70 C with epidermal heating minimized when us- marked induction of tropoelastin, fibrillin, as well
ing insulated needles. A reverse thermal gradient as procollagens 1 and 3 by 28 days posttreatment.
is created, with the temperatures highest in the An active dermal remodeling process driven by the
deeper levels, contrasting laser’s skin heating. collagen chaperone HSP47 leads to complete
Radiofrequency microneedling overcame the ob- replacement of RTZs with new collagen by
stacles with laser neck treatment, enabling effec- 10 weeks posttreatment. RTZs are observed
tive, high-energy delivery without significant through day 28 posttreatment but are replaced
downtime or risks. In addition, RFM heat is by new dermal tissue by 10 weeks. Reticular
294 Weiner

dermal volume, cellularity, HA, and elastin content induced coagulated columns showed mixed
increase. Furthermore, using immunohistochem- cellular infiltration, neovascularization, and granu-
ical and polymerase chain reaction studies, evi- lation tissue formation. Microneedle depth and
dence of profound neoelastinogenesis following RF conduction times, but not energy level, signifi-
RF treatment of human skin is demonstrated. cantly affected histometric values of RF-induced
The combination of neoelastinogenesis and neo- dermal coagulation. Microneedle RF treatment
collagenesis induced by treatment with the frac- affected adnexal structures by coagulating follic-
tional microneedling RF system may provide a ular epithelium and perifollicular structures.
reliable treatment option for skin laxity and/or rhy- Type 1 collagen, the predominant type of
tids.” There is a direct correlation to higher levels collagen in the skin, is composed of a triple-
of HSP47 and fibroblast proliferation to higher en- helical polypeptide structure stabilized with cross-
ergies delivered. linking. The immediate effect of heating is thick-
ening and contraction of the collagen fibers. This
is due to destruction of the heat-labile crosslinks
HISTOLOGY of collagen with transformation of the highly orga-
In a 2014 study by Zheng and colleagues,20 skin nized fiber system into a gel state.21 Tissue tension
samples that were taken immediately after RFM in human skin increases because, although the fi-
treatment showed that the RF-induced coagulated bers become shorter, the heat-stable crosslinks
columns in the dermis formed a cocoon-shaped between molecules are maintained, thus
zone of subablative thermal injury (Fig. 2). Four increasing the rubber-elastic properties of the
days after the treatment, skin specimens demon- collagen polymer. The heat-modified tissues then
strated re-epithelialization, and the dermal RF- undergo remodeling associated with fibroplasia

Fig. 2. Columns of coagulation created by an insulated RFM device with a variable-depth tip. (Courtesy of Med-
ical and Science Affairs, Lutronic Corporation, Gyeonggi-do, South Korea.)
 Radiofrequency Microneedling 295

and new collagen deposition.22 This is the process vary from 0.37 mm (eyelids) to over 2 mm. Acne
of collagen denaturing and is seen in conjunction scars and hyperhidrosis require deeper treat-
with the coagulation process noted above (Box 1). ments, as deep as 2.5 to 3.5 mm in some cases.
The fixed-length devices can work around this
INSULATED VERSUS NONINSULATED inherent problem by offering more than 1 tip, which
NEEDLES adds additional costs.
Although dialing in a depth sounds eloquent, the
Insulated needles theoretically allow for RF energy exact location of the RTZ is not likely to lie pre-
placement into the dermis while protecting the cisely at the depth chosen (Box 2).
epidermis from most of the heat. There will always If the operator does not hold the handpiece
be some heat transmitted superficially from the perpendicular to the skin or without enough pres-
deeper layers just through proximity and conduc- sure, more superficial than desired RTZs will
tion as the heat gradually dissipates. Also, there result. “Kickback” from the skin resistance is
may be heat transferred through the insulation, another reason for inexact RTZ placement.
particularly with more aggressive treatment set- Thicker/scarred skin, dull needles (from poor
tings. Energy can transmit superficially along the manufacturing quality control or from multiple
exterior of the protected needle, although this pulses), underpowered motor/solenoid can all
was not seen in the preliminary studies of 1 of lead to more shallow than anticipated depths.
the RFM devices when the energy was delivered The more needles there are, the more resistance
in a gel. Lastly, after several pulses, it is possible there is to penetration and the less likely the
there is breakdown of the insulation, although RTZs will be at the expected level. It must be
this has never been studied. kept in mind that there will be surrounding heating
Noninsulated needles will deliver a larger RTZ and coagulation of the exposed tips. Deeper heat-
throughout the entire length of the electrode. ing is possible, but, most likely, more superficial
Larger coagulation zones, despite being fractional, than expected RTZs will occur. Note that the
will heal slower than multiple small RTZs. high impedance of the fat in the subcutaneous tis-
Epidermal injuries may occur with the unprotected sue is somewhat resistant to the heat from RF.
needles, thus leading to higher risks in darker skin
types. In addition, wound care and downtime are
potentially prolonged as these superficial wounds MANUAL VERSUS MECHANICAL INSERTION
heal. With insulated needles, the epidermal injuries With mechanical insertion, user variability should
are limited to mechanical penetrations similar to be reduced. Unfortunately, many systems have
simple microneedling and behave similar to these underpowered motors/solenoids, which are un-
procedures with healing within 24 hours. able to overcome the inherent resistance of the
skin to get to their desired depths. With manual
VARIABLE VERSUS FIXED-LENGTH NEEDLES insertion devices, there is operator fatigue, which
will factor into the equation, particularly when
Variable lengths allow for more flexibility by the there are multiple treatments in 1 day or multiple
operator to treat different conditions and skin areas are treated on the same patient.
thickness. Even throughout the face, skin depths Some systems rely on the manual insertion of
fixed-length pins/needles. The completion of the
electric current requires the handpiece to be flush
Box 1 with the patient’s skin because the return elec-
Variations among radiofrequency
trode rests on the immediate adjacent skin. With
microneedling devices

 Insulated versus noninsulated needles

 Variable versus length needles Box 2
Variables preventing precise placement
 Manual versus mechanical insertion
 Bipolar versus monopolar  Technique of operator

 Temperature/impedance feedback versus  Depth chosen

none  Characteristics/resistance of tissues
 Pulse durations  Needle sharpness
 Bulk versus fractional heating  Number of needles
 Motor versus solenoid insertion  Power of motor/solenoid
296 Weiner

the rapidity of the treatment, there is bound to be preventative oral antibiotics will cut down on the
some “imperfect” pulses leading to arcing across incidence of acne significantly.
the epidermis with a resultant burn because of
inexact handpiece seating or fluid/blood of skin PROCEDURE DISCOMFORT
surface. In addition, these devices and the other
uninsulated needle devices produce superficial Probably the primary complaint with regard to
ablative injuries in the epidermis, creating a scar- RFM procedures is pain. There are many mea-
ring risk and additional downtime. If the energy sures, as outlined previously, to make the treat-
flow is analyzed, there is both bulk and fractional ment more comfortable. Pulse duration seems to
heating with these devices, which can create directly correlate to discomfort,9 and is why a de-
more downtime and risk versus a true fractional vice with long 2- to 4-second pulses requires
RTZ. tumescent anesthesia. It is promoted as a “1 and
done” procedure, so patients will often opt for
TEMPERATURE AND IMPEDANCE FEEDBACK this despite more downtime (large RTZs) and the
required tumescence. Many other RFM devices
Radiofrequency energy transmission is highly cause little to no pain after topical anesthesia.
dependent of the hydration of the skin, collagen, Careful observation will show whether the pene-
and electrolyte content, and many other variables tration of the microneedles is poor and energy de-
(see later discussion). It has also been established livery is low. In the author’s opinion, the efficacy of
that there is a threshold that is needed (65 C– “painless” RFM devices must be questioned. En-
70 C) to obtain coagulation and maximal neocolla- ergy delivery into the mid-dermis is inherently
genesis. One device monitors temperature and painful (Box 3).
impedance, which gives instantaneous feedback Procedure time varies according to the device
to the handpiece to maintain the temperature at and varies from about 15 to 60 minutes. Bleeding
67 C during its 3- to 5-second pulse. We also is usually minimal and should be wiped with sterile
know that too much current causes desiccation gauze, which is particularly important when the
and termination of energy flow. Another device surface electrode completes the circuit, as is true
monitors impedance and, through a feedback of a few devices. Taking breaks to allow the patient
loop, delivers a specified amount of energy during to “regroup” is sometimes necessary, but should
the pulse. Unfortunately, most of the RFM devices not prolong the procedure too long (Box 4).
use no tissue monitoring and results are not opti-
mized (Table 1). TREATMENT PARAMETERS

TREATMENT PROTOCOLS Inherently, higher-energy treatments should yield

better results. Studies have shown that the amount
On the day of treatment, informed consent and of collagen produced is directly dependent on the
photographs are taken. Photos, with and without intensity of heating of the connective tissue.10,23–25
flash, should be obtained from both sides of the In a study by Hruza and colleagues,26 higher-
face, at 0 , 45 , and 90 , with and without expres- energy treatments yielded better clinical results.
sion. For further documentation, 3D photos should In contrast, a 5-person study (performed by the
be taken, if available. The treated area should be author) in which 7–8 J/pulse was given, the patient
cleansed, and topical anesthetic should be results were deemed similar to patients treated
applied. Typically, a compounded mixture of beta- with 3–5 J/pulse, but the downtime was extended
caine, lidocaine, and tetracaine is commonly used, to 3 to 4 weeks (redness, grid marks). This down-
but offices have their preferences for a variety of time was unacceptable in the author’s opinion and
topical anesthetics. After the appropriate time was contradictory to the attractiveness of minimal
period, the cream/ointment is removed, and the downtime RF procedures. In a similar study using
face is again cleaned and sterilized. Rubbing fractional bipolar RF comparing higher versus
alcohol, chlorhexidine, and hypochlorous acid moderate energy levels, there were more side ef-
are the preferred ways to prep the face before fects with the higher settings, but comparable re-
treatment. It is essential that sterility be maintained sults at 3 and 6 month follow-up.27 It seems like
during the procedure because there is a significant there is a plateau in which higher energies give
disruption of the skin’s epidermal barrier for the no additional benefit, but add to downtime and
next 12 to 24 hours. Postprocedure acne flairs side effects.
are often superficial infections related to lapses In studies with 1 particular RFM device, high
in sterile technique. In addition, application of treatment levels (TLs) with short pulse durations
topical clindamycin or hypochlorous acid or led to spikes in the impedance, which terminated
Table 1
Current radiofrequency microneedling devices

Needle Depth Motorized/

Device Company (mm) No. of Needles Insulated/Noninsulated Fractional/Bulk Manual Unique Characteristics
Infini Lutronic 0.25–3.5 49 Insulated Fractional Motorized High-energy painful; sounds
like stapler
Intensif Endymed 0.5–5.0 25 Noninsulated Fractional Motorized Max pulse duration 200 ms
limits energy; noninsulated
risks PIH
Profound Syneron 5 (at 25 10 Insulated Fractional Manual Pulse 3–5 s, painful;
Candela and 75 ) temperature feedback; skin
quality tip for cellulite
Secret Cutera 0.5–3.5 25/64 Noninsulated/Insulated Fractional Motorized Offers insulated and
noninsulated tips
Fractora Inmode Multiple tips 24/60/126 Noninsulated/Insulated Fractional Manual Energy flow risks epidermis––
up to 3 and bulk blister/PIH; fixed needle
depths
eMatrix Syneron 0.5 44/64 Noninsulated Fractional Manual Energy flow risks epidermis––
Candela and bulk blister/PIH; fixed needle
depths
Vivace Aesthetics 0.5–3.5 36 Insulated Fractional Motorized Motor underpowered?
Biomedical
Intracel Jeisys Perigee 0.1–2.0 36 Insulated Fractional Motorized Has monopolar mode to get

Radiofrequency Microneedling
deeper penetration
Genius Lutronic 0.5–4.5 49 Insulated Fractional Motorized Impedance feedback to
optimize energy; fewer side
effects
Voluderm Lumenis 0.6/1.0 24/36 Noninsulated Fractional Manual RF during entire pulse eases
insertion; PIH risk
Viva Venus Concept 0.5 160 Noninsulated Fractional Motorized SmartScan changes energy
density without changing
tip; resurfaces
Morpheus8 Inmode 2–4/8 25 Insulated Fractional Motorized Able to destroy fat with up to
8 mm depths

297
298 Weiner

Box 3 Box 6
Measures to assist in patient comfort when Short-term complications
topical anesthetics do not fully accommodate a
pain-free treatment  Bruising, petechia

 Nerve blocks  Acne flair

 Superficial skin injections with anesthetic––  Superficial infection

“superficial skin block” with a multiple-  Persistent “grid/track” marks
needle injector
 Redness and edema
 Tumescent anesthesia
 Superficial burn
 Oral narcotics or antianxiolytics
 Postinflammatory hyperpigmentation
 Nitrous oxide/oxygen mixture––fixed 50%/
50% ratio
 Cold air/cold devices/ice––forced air coolers the RF pulses prematurely. Histologically, this
 Vibration––gate theory phenomenon was attributed to tissue desiccation
 “Talkasthesia” surrounding the RTZs. The RF energy could not
propagate through the tissue depleted of water.
 Music (room or headphones)
There are certain devices with temperature or
impedance measurement built into the needles
Box 4 to give feedback, with adjustments of the energy
Techniques to minimize risks/downtime/ output performed automatically. The devices with
complications
feedback will give a more definitive and consistent
 Always keep the handpiece perpendicular in delivery on energy than one without this feature
all directions to the skin because there are numerous variables affecting
impedance (as previously stated). Studies per-
 Maintain firm pressure on the handpiece to
ensure appropriate depth of the needles formed by the author using one particular device
have shown that optimal energy delivery was ob-
 Avoid stacking pulses
tained using lower TLs with longer pulse durations
 Allow for skin cooling––alternate sides if mul- (300–500 ms) rather than short pulses with higher
tiple passes/small areas require breaks before TLs. Second and third passes transmit higher en-
additional passes ergies because the heat from pervious passes
 Choose appropriate power settings and lowers the impedance of the tissue.22
depths for the skin condition/area of body Another consideration for choosing energy pa-
or face/skin type rameters is the size of the resultant RTZs. During
 Maintain sterility throughout procedure the healing process, replacement of the RTZs
 Avoid superficial depths in Fitzpatrick skin with newly formed collagen, there will be faster
type IV-VI repair with smaller RTZs because of the higher sur-
face area to volume ratio. There will be longer
 Higher energies should be reserved for
downtimes with larger RTZs and more risk if the
deeper passes only
pulse is not placed perfectly. The Profound

Box 5
Other instructions given to the patient Box 7
RFM is currently being used for multiple
 Avoid all make up application until the
indications
following day
 Apply the recommended topicals (healing  Aging––wrinkles and tightening
gels, growth factor serums similar to posta-  Acne scars
blative laser)
 Acne
 Sun exposure––best practice is not estab-
lished; safer to avoid sun  Axillary hyperhidrosis
 Exercise–no restrictions  Cellulite
 Elevate the head of treat area with several  Striae––stretch marks
pillows to decrease edema for 2 days  Hair thinning/alopecia
 Cleanse the skin before sleeping and in the  Rosacea/postinflammatory erythema
morning with gentle cleanser
 Radiofrequency Microneedling 299

Table 2
Table of studies

No. of
Patients Findings of Study/
Indication Author(s), Year In Study Purpose Paper
Antiaging Alexiades-Armenakas 25 Compare RFM RFM improved skin
et al,37 2010 with facelift laxity 37% of facelift
with less risk
Antiaging Alexiades-Armenakas 100 Neck and face 100% improved,
et al,38 2013 laxity/wrinkles average 25%
wrinkle reduction;
66.7 C, 4.2 s optimal;
90% satisfied
Antiaging Calderhead 499 Safety and wrinkles 80%–88% satisfaction,
et al,39 2013 minimal adverse
effects (AE), types
I-V
Periorbital rytids Kim et al,40 2013 11 Periobital wrinkles 10/11 very satisfied
after 3 treatments;
minimum
downtime/side
effects
Antiaging Hruza et al,26 2009 35 Skin quality and 80%–90% had
wrinkles improvement in skin
brightness,
tightness,
smoothness
Neck Clementoni & 33 Neck tightness Decreased
Munavalli,34 cervicomental and
2016 gnathion angles of
28.58 and 16.68
Acne scars Park 20 Acne scars All had grade 2
et al,31 improvement in
2016 scars or greater
Acne scars Chandrashekar 31 Acne scars skin 80% grade 2, 20%
et al,33 2014 types 3–5 grade 1
improvement; PIH 5
track marks 2
Acne scars Oblepias,41 20 Acne scars 72% had great or very
2010 great improvement
Axillary Kim et al,42 20 Hyperhidrosis Hyperhidrosis Disease
hyperhidrosis 2013 Severity Scale (HDSS)
scores 3.5 baseline
to 2.3 after 8 wk
Axillary Naeini et al,43 2015 25 Sham control study 79% decreased HDSS
hyperhidrosis scores by 1%–2%,
80% had 50%
satisfaction or
higher
Cellulite Alexiades 50 Cellulite 93% success rate at
et al,44 2018 6 mo
Abdominal striae Harmelin 22 Bipolar RF plus 21.6% decrease in
et al,45 2016 RFM/Light depth, no change in
width
(continued on next page)
300 Weiner

Table 2
(continued )

No. of
Patients Findings of Study/
Indication Author(s), Year In Study Purpose Paper
Abdominal striae Naeini 6 RFM with/without Better with CO2
et al,46 2016 CO2
Acne vulgaris Lee 18 Acne control All had grade 2–4
et al,47 2012 improvement, none
worsened
Hair loss Yu 19 Minoxidil with/ Higher hair count and
et al,48 2018 without RFM thickness on RFM
side of scalp
Postinflammatory Min 25 Erythema Effective for
erythema et al,49 2015 postinflammatory
erythema; anti-
inflammatory and
antiangiogenic
effects
Acne vulgaris Lee 20 Sebum production Sebum decreased for
et al,50 2013 8 wk and returned
after 1 treatment
Acne scars Faghihi 25 RFM with/without Subcision 1 RFM
et al,51 2017 subcision better
Acne scars Cho 30 Large pores and 70% or more
and pores et al,52 2012 acne scars improvement in
large pores and acne
scars all patients
Acne vulgaris Kwon 25 Compare RFM RFM more prolonged
et al,53 2018 with laser results
split face
Acne and Min 20 Compare RFM RFM superior to
acne scars et al,54 2015 vs bipolar bipolar (epidermal)
(epidermal) RF RF
Acne vulgaris Kim 25 Acne reduction 78% acne reduction,
et al,55 2014 37% sebum
reduction
Safety Cohen 30 Safety with Minimal downtime
et al,35 2016 insulated needles and no AE
Acne scars/safety Ibrahimi 4 Safety in acne Safe without AE
et al,36 2015 scars/dark skin
Axillary Abtahi-Naeini 25 Long-term 45.9% relapse after 1 y.
hyperhidrosis et al,56 2016 effectiveness Higher body mass
index, more relapse
Axillary Chilukuri N/A Efficacy of RFM Beneficial for long-
hyperhidrosis et al,57 2018 term control of
sweating

produces the largest RTZs and is claimed to have be safe in this regard. Skin resurfacing with abla-
a 30% dermal coverage with its “1and done” tive and nonablative lasers can target the
treatments. epidermis––pigmentation, scarring, fine lines––
which are not addressed with most of the RFM de-
vices. To address acne scarring/volume deficits,
ADJUNCTIVE TREATMENTS
chemical reconstruction of skin scars using tri-
The RFM procedures are often done in combina- chloroacetic acid, dermal fillers, subcision, and
tion with other procedures and have proven to platelet-rich plasma (PRP) have been performed
 Radiofrequency Microneedling 301

on the same day by the author without any colleagues43 suggested relapse in 1 year in 46%
increased side effects or risks. In a 2017 study of patients. Cellulite treatment showed improve-
by Dr. Lim, various hyaluronic acid and calcium hy- ment in the study by Alexiades. Stretch marks
droxyapatite fillers were injected into a test sub- showed improvement when used in combination
ject’s back. After treating the areas with RFM, with lasers but width was unchanged. A split
biopsies were taken to access the effect on the head study showed RFM was beneficial in combi-
fillers. Findings showed that there was no effect nation with minoxidil versus minoxidil alone.
on the fillers at all energies levels. PRP (high con- Improvement in controlling redness related to ro-
centration 5–9) seems to help speed up the heal- sacea and postinflammatory erythema has also
ing process. Studies have shown better results for been shown with RFM.
acne scars when PRP is used in conjunction with
microneedling than microneedling alone. Postpro- SUMMARY
cedure use of light-emitting diodes-low laser light
at 830 nm seems to calm the skin, improves heal- RFM is a significant advance over traditional RF
ing times, and improves outcomes.28 devices for skin tightening with improvements in
safety and efficacy. Energy delivery is efficient
POSTPROCEDURE CARE into the dermis with minimal disruption of the
epidermis, particularly for the insulated needle de-
The microneedle channels stay patent for varying vices. The devices that monitor tissue characteris-
durations, dependent on the size of needles, tics (temperature and impedance) should optimize
depth, and energies, but it is estimated to be for patient outcomes and safety. RFM should be
6 to 12 hours. It is imperative that the patient main- considered the new standard for treating acne
tain a clean environment around the treat area for scarring, particularly in darker skin types, as well
at least this amount of time. There are cases of as the minimal invasive neck rejuvenation/laxity
granuloma formation following microneedling pro- solution.
cedures with topical therapies,29 so caution is
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