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`H o t T o p i c sH o t T o p i c s
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`Nonablative Laser Technology: Radiofrequency
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`According to the author, nonablative radiofrequency
`treatment will not replace standard surgical rhytidecto-
`my, but it may play an important role in cosmetically
`improving early skin laxity. He describes a noninvasive
`skin tightening approach that uses volumetric heating
`of the entire dermis, protecting the epidermis from
`blistering with a cryogen-cooled contact probe.
`(Aesthetic Surg J 2004;24:180-181)
`
`Every 8 seconds, a baby boomer turns 50, and cur-
`
`rently 80 million Americans fall into this catego-
`ry. Described as a youth-oriented generation,
`baby boomers vigorously pursue a youthful appearance,
`often seeking out noninvasive cosmetic treatments.
`In the last 5 years a variety of lasers and light sources,
`emitting either visible or near-infrared wavelengths and
`promoting collagen formation, have become available.1-9
`Dermal injuries caused by these technologies, through
`wounding of the superficial papillary dermis or through a
`direct superficial vascular effect, lead to a cascade effect
`that results in new superficial papillary dermal collagen
`formation. Although early results suggested that such an
`approach could be used to decrease rhytides, these dermal
`remodeling techniques are now more commonly used to
`improve skin tone and texture. Despite extensive develop-
`ment of cosmetic laser treatments over the last 4 decades,
`no noninvasive treatment has been successful in promoting
`skin tightening. With the advent of nonablative radiofre-
`quency (RF) treatment, this is beginning to change.
`Over the last 2 years, my skin center has been one of
`several evaluating the skin-tightening effect of a nonabla-
`tive cryogen-cooled RF device, ThermaCool TC
`(Thermage Corp., Hayward, CA). This new approach to
`noninvasive skin tightening employs volumetric heating of
`the entire dermis; the epidermis is protected from blistering
`with a cryogen-cooled contact probe. Theoretically this
`approach leads to controlled uniform heating at consider-
`ably greater depths than those previously achieved with
`lasers and light sources. This deeper volumetric heating is
`thought to cause some initial collagen contraction that is
`followed by secondary collagen synthesis and repair.
`
`David J. Goldberg, MD,
`Hackensack, NJ, is a board-cer-
`tified dermatologist.
`
`The ThermaCool TC
`device delivers treatment to
`skin tissue in 3 stages through
`a handpiece that combines
`heating and contact-delivered
`cryogen cooling functions: (1)
`In the precooling stage, the
`cryogen coolant is sprayed
`inside the treatment tip to
`precool the skin surface; the
`coolant does not actually
`make contact with the skin.
`(2) During the heating stage, RF energy is delivered to the
`skin, with resultant resistive heating; simultaneous epi-
`dermal cooling also takes place. (3) Finally, during the
`postcooling stage, cooling continues even after applica-
`tion of RF energy has ended.
`This combination of volumetric heating with contact
`cooling leads to a reverse thermal gradient characterized
`by a higher tissue temperature in the deeper dermis than
`in the epidermis and upper dermis. Heat-induced collagen
`contraction occurs, with uncoiling of the triple helix
`resulting from thermal denaturation of hydrogen bonds.
`This collapse of the molecule increases the fibril diameter
`and causes longitudinal contraction and tightening. One
`can observe immediate collagen contraction and, later,
`secondary collagen production. Another characteristic of
`the RF device is that it is colorblind; all affected tissues
`(with and without pigment) are heated.
`In the initial multicenter study, which led to Food and
`Drug Administration clearance, RF energy was applied to
`the forehead area in 86 patients in an attempt to lift and
`tighten drooping eyebrows and eyelids.10 Delivered ener-
`gies ranged between 59-140 J/cm2. Only the forehead was
`treated. Four months after treatment, 61% of treatment
`areas showed significant improvement with regard to
`Fitzpatrick wrinkling score; after 6 months, 80% of treat-
`ment areas showed even greater improvement. Objective
`analysis measuring brow position changes 4 months after
`treatment demonstrated that 60% of treated patients had
`some degree of brow elevation. Six months after treat-
`ment, 80% of treated patients demonstrated some degree
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`A E S T H E T I C S U R G E R Y J O U R N A L ~ M a r c h / A p r i l 2 0 0 4
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`BTL EX1016
`IPR2024-00703
`U.S. Patent No. 8,961,511
`
`

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`H o t T o p i c s
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`Downloaded from https://academic.oup.com/asj/article/24/2/180/200905 by guest on 22 February 2024
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`A
`
`B
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`Figure. A, Pretreatment view of a 46-year-old woman. B, Posttreatment view 6 months after 1 RF nonablative treatment of the forehead to lift the brows
`and reduce upper eyelid sagging. Note that the patient’s eyelids are somewhat lifted. This is where the results of this treatment are commonly seen.
`
`of brow elevation (Figure). Some of these patients show
`persistence of the results 1 year after treatment.
`In a subsequent study, 119 of 140 original study sub-
`jects underwent 1 to 4 forehead treatments. Thirty-five
`subjects were placed randomly into each treatment
`group. Each group was treated with the same parameters
`as the original study group. Each treatment consisted of
`one pass of RF energy to the treatment area. Subjects in
`the multiple treatment study group were treated at 1-
`month intervals. Increased treatment led to improved
`clinical results, measured subjectively.11 Most recently,
`this approach has been used to tighten early sagging
`jowls and neck skin laxity.
`Introduction of nonablative RF treatment will not
`replace standard surgical rhytidectomy. However, such
`treatment may play a major role in the cosmetic improve-
`ment of early skin laxity. Generally, the best candidates
`for this treatment are younger. In addition, patients who
`wish to postpone surgery, with its associated risk of com-
`plications, and who are willing to accept the subtler RF-
`induced changes can now be treated in a noninvasive
`manner. The nonablative RF approach is best combined
`with other nonsurgical approaches such as Botox, filler
`agents, and other nonablative laser treatments.
`Improvement with RF treatment can be subtle. ■
`
`References
`1. Bjerring P, Clement M, Heickendorff L, Egevist H, Kiernan M.
`
`Selective non-ablative wrinkle reduction by laser. J Cut Laser Ther
`2000;2:9-15.
`
`2. Goldberg DJ, Whitworth J. Laser skin resurfacing with the Q-switched
`Nd:YAG laser. Dermatol Surg 1997;23:903-907.
`
`3. Goldberg DJ, Metzler C. Skin resurfacing utilizing a low-fluence
`Nd:YAG laser. J Cut Laser Ther 1999;1:23-27.
`
`4. Goldberg DJ. Nonablative subsurface remodeling: clinical and histolog-
`ic evaluation of a 1320nm Nd:YAG laser. J Cut Laser Ther
`1999;1:153-157.
`
`5. Goldberg DJ. Nonablative resurfacing. Clin Plastic Surg 2000;27:287-
`292.
`
`6. Goldberg DJ. Full-face nonablative dermal remodeling with a 1320nm
`Nd:YAG laser. Dermatol Surg 2000;26:915-918.
`
`7. Goldberg DJ, Cutler KB. Nonablative treatment of rhytids with intense
`pulsed light. Lasers Surg Med 2000;26:196-199.
`
`8. Goldberg DJ. Histologic changes after treatment with an intense
`pulsed light. J Cut Laser Ther 2000;2:53-56.
`
`9. Bitter PJ. Noninvasive rejuvenation of photoaged skin using serial,
`full-face intense pulsed light treatments. Dermatol Surg 2000;26:835-
`843.
`
`10. Goldberg DJ, Koch J, Burns J, Geronemus R. A new nonablative
`radiofrequency device to tighten tissue: a randomized trial comparing
`a single treatment to multiple treatments. Laser Surg Med
`2003;suppl 15:69.
`
`11. Fitzpatrick RE, Geronemus R, Goldberg D, Kaminer M, Kilmer S, Ruiz-
`Esparza J. Multicenter study of a new non-ablative radiofrequency
`device to tighten facial issue. Laser Surg Med 2003;33:232-242.
`
`Reprint requests: David Goldberg, MD, 20 Prospect Ave., Suite 702,
`Hackensack, NJ 07601; e-mail: drdavidgoldberg@skinandlasers.com.
`1090-820X/$30.00
`Copyright © 2004 by The American Society for Aesthetic Plastic Surgery, Inc.
`doi:10.1016/j.asj.2004.01.002
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`Nonablative Laser Technology: Radiofrequency
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`A E S T H E T I C S U R G E R Y J O U R N A L ~ M a r c h / A p r i l 2 0 0 4
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