DOI: 10.1111/exd.12391
Original Article
www.wileyonlinelibrary.com/journal/EXD
The clinical experience and efficacy of bipolar radiofrequency with fractional photothermolysis for aged Asian skin Hirotaka Akita1,2, Ryosuke Sasaki1, Yusuke Yokoyama3, Kei Negishi4 and Kayoko Matsunaga1 1 Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; 2Division of Dermatology, Koyu Clinic, Ichinomiya, Aichi, Japan; 3Department of Dermatology, Daido Hospital, Nagoya, Aichi, Japan; 4Aoyama Institute of Women’s Medichine, Tokyo Women’s University, Aoyama, Tokyo, Japan Correspondence: Hirotaka Akita, M.D., Ph.D., Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Aichi 470-1192, Japan, Tel.: +81-562-93-9256, Fax: +81-562-93-2198, e-mail: [email protected]
Abstract: Bipolar radiofrequency (RF) technology is developed based on fractional thermolysis, and the literature concerning the efficacy of the rejuvenation and treatment of acne scars has been reported in Europe and the United States of America. Therefore, we examined bipolar RF treatment using fractional thermolysis to evaluate the efficacy and safety of the treatment of Asian photoaging skin, particularly ‘wrinkles’ and ‘sagging.’ Ten Japanese women (mean age: 58.6, skin type III–IV) received three fractional bipolar RF treatments every 4–6 weeks. For the objective evaluation, we evaluated the improvement of the wrinkles on the forehead, lateral canthus (crow’s feet) and lower eyelid, and the sagging of the nasolabial fold using digital photographs captured using VisiaTM. For the subjective evaluation, the participants were asked to describe the improvements observed in the wrinkles on the forehead, lateral canthus (crow’s feet) and lower eyelid, and sagging nasolabial fold and to evaluate the level pain experienced using a 10-point VAS score. The objective evaluation in each category showed significant improvements in the wrinkles on the lateral canthus (crow’s feet) and lower eyelid. As for the nasolabial fold, 60% of the subjects showed improvements, scoring from
good to excellent (51–100% improvement), although there was a little improvement of the wrinkle on the forehead. Similar improvements were observed in the subjective evaluation. During each treatment, oedema and erythema were observed in all participants, but the oedema disappeared the following day in all cases. However, mild erythema persisted for an average of 3.1 days. Micro debris disappeared after an average of 5.2 days. The participants were satisfied, as we allowed them to apply make-up the next day. There were no other severe adverse reactions observed during the treatment. The 10-point VAS score was 3.8, and no participants dropped out due to discomfort. Little improvement was observed in the forehead wrinkles in either the objective or the subjective evaluation. The results obtained in this study indicate that fractional bipolar RF is an effective and safe treatment for the ‘wrinkling’ and ‘sagging’ of Asian photo-aging skin.
Introduction
300 GHz. In contrast to most lasers, which target a particular chromophore, RF depends on the electric property of the target tissue and does not require any chromophore. Therefore, RF can be used safely for all skin types. The mechanism underlying RF treatment is to generate high thermal energy through the electrical resistance of skin, which tightens dermal connective tissue. Based on the action circuit, there are two RF types: mono-polar and bipolar. Mono-polar RF functions in deeper areas of the skin. In recent years, a bipolar RF device, with fractional resurfacing, was developed. This technique was referred to as ‘sublative rejuvenation’, reflecting the fact that skin remodelling occurs in a region deeper than the epidermal area, and the ablative damage through heating is less that resulting from ablative laser. This method has been primarily used in America and Europe not only to rejuvenate aging (10) and/or photo-damaged skin, but also to treat acne and/ or acne scarring (11,12). Therefore, the aim of this study was to evaluate the efficacy and safety of a bipolar RF using an FP device for facial photo-damaged skin in Asian individuals, particularly for ‘wrinkle’ and ‘sagging’.
The treatments for aging skin, particularly photo-aging skin, have advanced remarkably, and many energy-based treatments, such as laser (1,2), intense pulse light (IPL) (3–5) and radiofrequency (RF) (6–8), are used for skin rejuvenation. Among Asian patients, lasting postinflammatory hyperpigmentation (PIH), caused after ablative laser resurfacing, is a major concern. Therefore, fractional photothermolysis (FP) (9) was introduced in 2004, which revolutionized the field of laser resurfacing. With FP, the thermal energy is applied to numerous, nonsequence alleys of the microscopic treatment zone (MTZ). The surrounding skin is left intact and serves as a viable tissue store, promoting epidermal turnover and the regeneration of dermal collagen, while controlling the potential side effects. The efficacy and safety of a fractional resurfacing treatment has been reported in various skin conditions, such photo-damaged skin, acne and/or acne scarring, atrophic striae and syringoma. Furthermore, the side effects of post-FP treatment on Asian skin have been remarkably reduced compared with other ablative laser treatments. Radiofrequency is an effective treatment for skin tightening, such as sagging and/or laxity (6–8). RF involves treatment using non-ionized electromagnetic waves at a frequency of 3 kHz–
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Experimental Dermatology, 2014, 23 (Suppl. 1), 37–42
Key words: bipolar – fractional photothermolysis – radiofrequency – sagging – tightening – wrinkle
Accepted for publication 24 March 2014
Subjects The subjects, aged 30 and older with various signs of photo-aging, such as wrinkles, laxity and/or sagging, were recruited at the
37
Akita et al.
Department of Dermatology, Fujita Health University Hospital or Koyu Clinic. Individuals with a history of laser treatment or other cosmetic treatments on the face or having used isotretinoin within 6 months before this study, a history of hypertrophic scarring or keloid formation, a history of any skin diseases involving the treatment area, a history of photosensitivity disorders, the use of drugs causing photosensitivity, or were pregnant or lactating, were excluded from this study. All patients were informed of the benefits, risks and potential complications of the treatment before enrolment, and informed consent was obtained from each participant. This study was conducted according to the Declaration of Helsinki Principles and approved by the institutional ethics committee of our institution. None of the authors have any conflict of interests pertaining to commercial sources.
Treatment device and methods We used eMatrixTM (Syneron & Candela, Irvine CA, USA), which delivers fractionated bipolar RF, contains a disposable single-use treatment tip, consisting of eight parallel rows and columns of bipolar gold-coated electrode pins, comprising a total of 64 pins in a 12 9 12 mm area. A total of 400 pulses are available on each of the single-use tips. These pins are arranged in alternating rows of positive and negative electrode pins. Program A showed less ablation, but greater lateral heating around the epidermal area, whereas Program C was the most ablative, showing the least lateral heating at an area deeper than the middle layer of the dermis. The energy output varied according to the program (peak energy of 25 J), with a 5% or 10% coverage rate, through a 200-lm-diameter pin.
No topical and local anaesthesia was used during the treatment process. Instead of anaesthesia, an iced mask was applied before and after the procedure for approximately 5 min, and an air cooler was used during the procedure. Before treatment, the face was washed well using a mild cleanser and dried completely, as dry skin is required for the flow of RF energy using this device. Each subject received three treatments to the entire face every 4–6 weeks. Program B, with a 5% coverage rate, was selected in this study, as we needed to apply the heat reaction to an area deeper than the epidermis to improve wrinkling and sagging, and the full ablation, as applied in Program C, was not required. The preferred irradiation end point was mild erythema and/or mild oedematous erythema on the treated area. The treatment was delivered in a few passes, and the rate of overlapping did not exceed more than 15%. A new tip was used for each subject. The subjects were allowed to apply makeup on next day after treatment and the individuals were instructed to avoid sun exposure during this study.
Evaluation methods Objective evaluation Using the digital photographs captured using VisiaTM (Canfield Scientific Inc., Fairfield NJ, USA), we assessed the improvement in the wrinkles on the forehead, lateral canthus (crow’s feet) and lower eyelid, and the sagging of the nasolabial fold. The grading of wrinkles on the lateral canthus (crow’s feet) and lower eyelid was determined using the guidelines of the Japanese Cosmetic Science Society (Fig. 1), and the changes between pretreatment and two months after receiving three RF treatments were compared. Furthermore, each grading of wrinkles was classified as (i) mild, (ii) moderate, (iii) severe and subsequently scored (Table 1).
Grade 0
Grade 1
Grade 2
Grade3
Grade 4
Grade 5
Grade 6
Grade 7
Figure 1. The guidelines of the grading on wrinkles from the Japanese Cosmetic Science Society.
38
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Experimental Dermatology, 2014, 23 (Suppl. 1), 37–42
Efficacy of bipolar radiofrequency in Asians
Table 1. The wrinkle score modified from the guideline of wrinkle from Japanese Cosmetic Science Society. Each grading of wrinkles was classified as (i) mild, (ii) moderate, (iii) severe and subsequently scored Mild
Moderate
Severe
0 1 4 7 10 13 16 19
0 2 5 8 11 14 17 20
0 3 6 9 12 15 18 21
(score)
crow's feet
20
lower eylid * p
Original Article
www.wileyonlinelibrary.com/journal/EXD
The clinical experience and efficacy of bipolar radiofrequency with fractional photothermolysis for aged Asian skin Hirotaka Akita1,2, Ryosuke Sasaki1, Yusuke Yokoyama3, Kei Negishi4 and Kayoko Matsunaga1 1 Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan; 2Division of Dermatology, Koyu Clinic, Ichinomiya, Aichi, Japan; 3Department of Dermatology, Daido Hospital, Nagoya, Aichi, Japan; 4Aoyama Institute of Women’s Medichine, Tokyo Women’s University, Aoyama, Tokyo, Japan Correspondence: Hirotaka Akita, M.D., Ph.D., Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Aichi 470-1192, Japan, Tel.: +81-562-93-9256, Fax: +81-562-93-2198, e-mail: [email protected]
Abstract: Bipolar radiofrequency (RF) technology is developed based on fractional thermolysis, and the literature concerning the efficacy of the rejuvenation and treatment of acne scars has been reported in Europe and the United States of America. Therefore, we examined bipolar RF treatment using fractional thermolysis to evaluate the efficacy and safety of the treatment of Asian photoaging skin, particularly ‘wrinkles’ and ‘sagging.’ Ten Japanese women (mean age: 58.6, skin type III–IV) received three fractional bipolar RF treatments every 4–6 weeks. For the objective evaluation, we evaluated the improvement of the wrinkles on the forehead, lateral canthus (crow’s feet) and lower eyelid, and the sagging of the nasolabial fold using digital photographs captured using VisiaTM. For the subjective evaluation, the participants were asked to describe the improvements observed in the wrinkles on the forehead, lateral canthus (crow’s feet) and lower eyelid, and sagging nasolabial fold and to evaluate the level pain experienced using a 10-point VAS score. The objective evaluation in each category showed significant improvements in the wrinkles on the lateral canthus (crow’s feet) and lower eyelid. As for the nasolabial fold, 60% of the subjects showed improvements, scoring from
good to excellent (51–100% improvement), although there was a little improvement of the wrinkle on the forehead. Similar improvements were observed in the subjective evaluation. During each treatment, oedema and erythema were observed in all participants, but the oedema disappeared the following day in all cases. However, mild erythema persisted for an average of 3.1 days. Micro debris disappeared after an average of 5.2 days. The participants were satisfied, as we allowed them to apply make-up the next day. There were no other severe adverse reactions observed during the treatment. The 10-point VAS score was 3.8, and no participants dropped out due to discomfort. Little improvement was observed in the forehead wrinkles in either the objective or the subjective evaluation. The results obtained in this study indicate that fractional bipolar RF is an effective and safe treatment for the ‘wrinkling’ and ‘sagging’ of Asian photo-aging skin.
Introduction
300 GHz. In contrast to most lasers, which target a particular chromophore, RF depends on the electric property of the target tissue and does not require any chromophore. Therefore, RF can be used safely for all skin types. The mechanism underlying RF treatment is to generate high thermal energy through the electrical resistance of skin, which tightens dermal connective tissue. Based on the action circuit, there are two RF types: mono-polar and bipolar. Mono-polar RF functions in deeper areas of the skin. In recent years, a bipolar RF device, with fractional resurfacing, was developed. This technique was referred to as ‘sublative rejuvenation’, reflecting the fact that skin remodelling occurs in a region deeper than the epidermal area, and the ablative damage through heating is less that resulting from ablative laser. This method has been primarily used in America and Europe not only to rejuvenate aging (10) and/or photo-damaged skin, but also to treat acne and/ or acne scarring (11,12). Therefore, the aim of this study was to evaluate the efficacy and safety of a bipolar RF using an FP device for facial photo-damaged skin in Asian individuals, particularly for ‘wrinkle’ and ‘sagging’.
The treatments for aging skin, particularly photo-aging skin, have advanced remarkably, and many energy-based treatments, such as laser (1,2), intense pulse light (IPL) (3–5) and radiofrequency (RF) (6–8), are used for skin rejuvenation. Among Asian patients, lasting postinflammatory hyperpigmentation (PIH), caused after ablative laser resurfacing, is a major concern. Therefore, fractional photothermolysis (FP) (9) was introduced in 2004, which revolutionized the field of laser resurfacing. With FP, the thermal energy is applied to numerous, nonsequence alleys of the microscopic treatment zone (MTZ). The surrounding skin is left intact and serves as a viable tissue store, promoting epidermal turnover and the regeneration of dermal collagen, while controlling the potential side effects. The efficacy and safety of a fractional resurfacing treatment has been reported in various skin conditions, such photo-damaged skin, acne and/or acne scarring, atrophic striae and syringoma. Furthermore, the side effects of post-FP treatment on Asian skin have been remarkably reduced compared with other ablative laser treatments. Radiofrequency is an effective treatment for skin tightening, such as sagging and/or laxity (6–8). RF involves treatment using non-ionized electromagnetic waves at a frequency of 3 kHz–
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Experimental Dermatology, 2014, 23 (Suppl. 1), 37–42
Key words: bipolar – fractional photothermolysis – radiofrequency – sagging – tightening – wrinkle
Accepted for publication 24 March 2014
Subjects The subjects, aged 30 and older with various signs of photo-aging, such as wrinkles, laxity and/or sagging, were recruited at the
37
Akita et al.
Department of Dermatology, Fujita Health University Hospital or Koyu Clinic. Individuals with a history of laser treatment or other cosmetic treatments on the face or having used isotretinoin within 6 months before this study, a history of hypertrophic scarring or keloid formation, a history of any skin diseases involving the treatment area, a history of photosensitivity disorders, the use of drugs causing photosensitivity, or were pregnant or lactating, were excluded from this study. All patients were informed of the benefits, risks and potential complications of the treatment before enrolment, and informed consent was obtained from each participant. This study was conducted according to the Declaration of Helsinki Principles and approved by the institutional ethics committee of our institution. None of the authors have any conflict of interests pertaining to commercial sources.
Treatment device and methods We used eMatrixTM (Syneron & Candela, Irvine CA, USA), which delivers fractionated bipolar RF, contains a disposable single-use treatment tip, consisting of eight parallel rows and columns of bipolar gold-coated electrode pins, comprising a total of 64 pins in a 12 9 12 mm area. A total of 400 pulses are available on each of the single-use tips. These pins are arranged in alternating rows of positive and negative electrode pins. Program A showed less ablation, but greater lateral heating around the epidermal area, whereas Program C was the most ablative, showing the least lateral heating at an area deeper than the middle layer of the dermis. The energy output varied according to the program (peak energy of 25 J), with a 5% or 10% coverage rate, through a 200-lm-diameter pin.
No topical and local anaesthesia was used during the treatment process. Instead of anaesthesia, an iced mask was applied before and after the procedure for approximately 5 min, and an air cooler was used during the procedure. Before treatment, the face was washed well using a mild cleanser and dried completely, as dry skin is required for the flow of RF energy using this device. Each subject received three treatments to the entire face every 4–6 weeks. Program B, with a 5% coverage rate, was selected in this study, as we needed to apply the heat reaction to an area deeper than the epidermis to improve wrinkling and sagging, and the full ablation, as applied in Program C, was not required. The preferred irradiation end point was mild erythema and/or mild oedematous erythema on the treated area. The treatment was delivered in a few passes, and the rate of overlapping did not exceed more than 15%. A new tip was used for each subject. The subjects were allowed to apply makeup on next day after treatment and the individuals were instructed to avoid sun exposure during this study.
Evaluation methods Objective evaluation Using the digital photographs captured using VisiaTM (Canfield Scientific Inc., Fairfield NJ, USA), we assessed the improvement in the wrinkles on the forehead, lateral canthus (crow’s feet) and lower eyelid, and the sagging of the nasolabial fold. The grading of wrinkles on the lateral canthus (crow’s feet) and lower eyelid was determined using the guidelines of the Japanese Cosmetic Science Society (Fig. 1), and the changes between pretreatment and two months after receiving three RF treatments were compared. Furthermore, each grading of wrinkles was classified as (i) mild, (ii) moderate, (iii) severe and subsequently scored (Table 1).
Grade 0
Grade 1
Grade 2
Grade3
Grade 4
Grade 5
Grade 6
Grade 7
Figure 1. The guidelines of the grading on wrinkles from the Japanese Cosmetic Science Society.
38
ª 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Experimental Dermatology, 2014, 23 (Suppl. 1), 37–42
Efficacy of bipolar radiofrequency in Asians
Table 1. The wrinkle score modified from the guideline of wrinkle from Japanese Cosmetic Science Society. Each grading of wrinkles was classified as (i) mild, (ii) moderate, (iii) severe and subsequently scored Mild
Moderate
Severe
0 1 4 7 10 13 16 19
0 2 5 8 11 14 17 20
0 3 6 9 12 15 18 21
(score)
crow's feet
20
lower eylid * p
