An innovative technique for nonablative skin rejuvenation

As the science and technology of medicine continue to advance, some procedures that once required major surgical intervention are gradually being replaced by less invasive techniques. These minimally invasive procedures offer promising results without the prolonged recovery, discomfort, and complications often associated with traditional aesthetic surgical techniques.

The growing popularity and acceptance of nonsurgical techniques—office-based botulinum toxin injections; injectable filler materials; and nonablative modalities such as lasers, intense pulsed light, and radiofrequency—have defined a trend toward minimally invasive procedures that have been embraced by the facial plastic surgery community. How-ever, controversy persists over the effectiveness of these treatments, especially with the newer radiofrequency and nonablative laser procedures. Moreover, with the multitude of treatment options and emerging technologies available for rejuvenation of the lower face and neck, it is often difficult to determine which patients are the best candidates for a particular procedure.

Monopolar Capacitive Radiofrequency

One increasingly popular nonablative rejuvenation technology is monopolar capacitive radiofrequency (CRF). This skin-rejuvenation technique, developed by Thermage Inc (Hayward, Calif) more than 5 years ago, contracts and lifts skin, softens facial wrinkles, and defines contours—all without surgical incisions or significant recovery periods.

The manufacturer obtained its initial US Food and Drug Administration (FDA) clearance for the noninvasive treatment of periorbital wrinkles and rhytids in November 2002.1 The FDA approval for treating all facial wrinkles and rhytids, based on additional studies, was granted in June 2004.2

Although other forms of radiofrequency energy are used in a variety of medical applications, only the CRF procedure delivers uniform volumetric heat deep enough to nonablatively tighten and contour skin and subcutaneous tissue. Other aesthetic radiofrequency-based devices are technologically limited to superficial energy delivery and are sometimes combined with light energy–based devices to treat surface conditions. Because the procedure is nonablative and, in contrast to lasers and other light-based treatments, does not depend on absorption by target chromophores in the skin, it is amenable for use on all skin types.

How CRF Works

Unlike traditional skin-rejuvenation methods—deep chemical peels, dermabrasion, and ablative lasers that achieve their effect by removing the top layers of skin and allowing the skin to re-epithelialize gradually—the CRF treatment provides deep, uniform volumetric heat to the dermis while cooling, and therefore protecting, the epidermis.

The reverse thermal gradient created causes the skin’s collagen scaffold to contract immediately and, over time, stimulates new collagen growth. Recent findings suggest that CRF energy also preferentially conducts through subcutaneous collagen-based fibrous septae, which accounts for some of the 3-D contour changes  that have been observed.3

The procedure is performed with a sophisticated, computer-controlled treatment tip that precisely delivers CRF energy while simultaneously applying a cryogenic coolant to the skin surface. With each application of the treatment tip, the patient experiences cooling followed by a brief heat sensation as the radiofrequency energy is delivered.

Sensors within the tip carefully monitor skin-surface temperature, providing further protection against overheating by adjusting the delivery of cryogen. The application of cooling before, during, and after heating also makes the treatment more comfortable for the patient.

Patient Selection

All evaluations to date of the clinical efficacy of nonablative CRF treatment have documented the overall improvement of skin parameters.3–17 However, as with any aesthetic procedure, the appropriate selection of patients and management of realistic outcome expectations are crucial for ensuring satisfaction with the results. The key is for the treating physician to communicate clearly with the patient that this noninvasive alternative to surgery provides very real but comparatively modest skin tightening compared with invasive surgical techniques. Patients who insist on more dramatic results should be counseled to consider a surgical alternative.

There are relatively few contraindications to CRF treatment other than pregnancy, active dermatologic conditions, and implanted medical devices that may be susceptible to CRF energy. Caution should be exercised with patients who have atrophic skin as a result of radiation or other treatment, because the CRF field could penetrate deeper than anticipated and could impair the skin’s ability to produce collagen.

Treatment Technique

As with other new technologies, CRF treatment algorithms have evolved to optimize results, minimize complications, and improve patient comfort. The initial protocols specified providing the maximum amount of radiofrequency energy tolerated by the patient to achieve the greatest improvement with a single-pass treatment. Although effective, these high-energy treatment sessions were often uncomfortable for  the patient.4,9

 A landmark study by Zelickson et al demonstrated that an equivalent or greater amount of collagen denaturation can be induced with multiple passes of the CRF treatment tip over the same area at a lower energy level.18 This discovery, coupled with the development of faster and larger treatment tips, has facilitated the application of more efficacious and comfortable multiple-pass treatment algorithms without increasing the overall procedure time.

To discourage providers from using unnecessarily high—and potentially unsafe—energy levels, current treatment algorithms discourage topical, local-injection intravenous sedation or general anesthesia. Oral narcotic analgesics and short-acting anxiolytics taken 1 hour before the procedure are suggested as alternative methods for minimizing patient discomfort. This level of analgesia allows the provider to gauge the patient’s response to each treatment cycle to ensure a safe level of energy delivery. Many patients tolerate localized procedures, such as treatment of the brow area, with no medication at all.


Nonablative CRF treatment was initially approved by the FDA for periorbital rhytids, and several studies have documented significant brow-frame-height elevation, reduction of rhytids, and tightening of upper-eyelid skin.4–8,10,13 CRF treatment of the lower face and neck softens the nasolabial folds, reduces jowl volume, and accent­uates the cervicomental an­gle.3,7,9–12,14–16 When CRF skin tightening is combined with other minimally invasive procedures, even more dramatic im­provements can be achieved.6,8

In addition to tightening the skin and and reducing wrinkles, other intrinsic skin characteristics appear to be improved with CRF treatment. Reduction of skin-pore size is presumably related to increased collagen content in the skin.6 In addition, acne reduction is probably the result of sebaceous gland atrophy and the antibacterial effect of the heat generated in the dermis during CRF treatment.6,17 When patients are appropriately selected and prepared, and optimal CRF treatment settings are used, patient satisfaction is uniformly high, ranging from 75% to 100%.3,6,11–13,16

The incidence of complications with the CRF treatment is exceedingly low.4–7,10–13,15 Side effects include some transient erythema and mild edema, which typically resolve within 1–2 days. In the more than 100 patients that I have treated, persistent edema lasted for more than 1 week in only three patients and was resolved by treating it with a tapered dose of methylprednisolone. Skin numbness, particularly in the distribution of the greater auricular nerve, rarely occurs and always completely resolves with time because there is no anatomical disruption of the nerve.

Tiny superficial skin burns (less than 5 mm) occasionally occur and are typically self-limiting. Rare contour irregularities have been reported by the manufacturer with an estimated rate of 0.15% in more than 150,000 uses to date, most often in patients treated with high energy and profound levels of anesthesia. With the lower-energy, multiple-pass treatment algorithms, it is anticipated that even fewer adverse effects will be noted.

CRF Versus Facelift

Currently, the degree of skin tightening that can be achieved with single-pass CRF treatment is usually not equivalent to that achieved by a surgical procedure. The newer multiple-pass treatment algorithms have been reported to improve both the predictability and the extent of efficacy, but CRF treatment has not yet approached the standard of consistency and dramatic change that is associated with traditional surgical tech­­­niques.

When patients are fairly presented with the benefits and risks of surgical and nonsurgical alternatives, many of them will choose the more subtle tightening effect of a noninvasive CRF procedure because of its much shorter recovery time and lower probability of complications. Ultimately, the ability to provide a full range of treatment options allows the facial plastic surgeon to be more competitive in meeting the needs of patients.

Future Developments

The development of larger and faster treatment tips should facilitate continued reduction of treatment times and enable the treatment of large surface areas, such as the abdomen and the arms. With specialized treatment tips, controlled thermolysis of fatty tissue may be possible. The next generation of tips may allow precise lifting and contouring of ptotic skin and underlying structures, and may more reliably approach a surgical result.

At present, CRF treatment favorably compares with other forms of nonablative skin rejuvenation. CRF treatment is not currently intended to replace the more dramatic effects of invasive surgical procedures, although it is a good adjunct and may be combined successfully with other minimally invasive treatment modalities. It is an excellent addition to the facial plastic surgeon’s armamentarium to meet the needs of patients who are averse to surgical intervention. With further refinement of the technology and treatment algorithms, nonablative CRF treatment is an increasingly important tool for facial rejuvenation. PSP

Manoj T. Abraham, MD, is a clinical assistant professor in the Division of Facial Plastic and Reconstructive Surgery at the Department of Otolaryngology–Head and Neck Surgery at New York Medical College. Double-board-certified and fellowship trained, Abraham specializes in rejuvenation of the face and neck and has considerable research and clinical expertise in minimally invasive and nonsurgical techniques. He is the medical director of Facial Plastic, Reconstructive & Laser Surgery, PLLC, based at Vassar Brothers Medical Center in Poughkeepsie, NY. He can be contacted through his Web site,


 1. US Food and Drug Administration. Safety Summary. K021402. November 5, 2002. Available at: http://[removed][/removed].pdf Accessed August 3, 2005.

 2. US Food and Drug Administration. Safety Summary. K0040135. June 21, 2004. Available at: http://[removed][/removed].pdf Accessed August 3, 2005.

 3. Abraham MT, Ross EV. Current concepts in nonablative radiofrequency rejuvenation of the lower face and neck. Facial Plast Surg. 2005;21: 65–73.

 4. Bassichis BA, Dayan S, Thomas JR. Use of nonablative radiofrequency device to rejuvenate the upper one-third of the face. Otolaryngol Head Surg. 2004;130:397–406.

 5. Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M, Kilmer S, Ruiz-Esparza J. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med. 2003;33:232–242.

 6. Abraham M, Chiang S, Keller G, Rawnsley J, Blackwell K, Elashoff D. Clinical evaluation of nonablative radiofrequency facial rejuvenation. J Cosmet Laser Ther. 2004;6:136–144.

 7. Nahm WK, Su TT, Rotunda AM, Moy RL. Objective changes in brow position, superior palpebral crease, peak angle of the eyebrow, and jowl surface area after volumetric radiofrequency treatments to half of the face. Dermatol Surg. 2004;30:922–928.

 8. Koch RJ. Radiofrequency nonablative tissue tightening. Facial Plastic Surg Clin North Am. 2004;12:339–346.

 9. Jacobson LG, Alexiades-Armenakas M, Bernstein L, Geronemus RG. Treatment of nasolabial fold and jowls with a noninvasive radiofrequency device. Arch Dermatol. 2003;139:1371–1372.

10. Narins DJ, Narins RS. Nonsurgical radiofrequency facelift. J Drugs Dermatol. 2003;2:495–500.

11. Fritz M, Counters JT, Zelickson BD. Radiofrequency treatment for middle and lower face laxity. Arch Facial Plast Surg. 2004;6: 370–373.

12. Alster TS, Tanzi E. Improvement of neck and cheek laxity with nonablative radiofrequency device: A lifting experience. Dermatol Surg. 2004;30: 503–507; Hughes P. Comment. Dermatol Surg. 2004;30:1430.

13. Ruiz-Esperza J. Noninvasive lower eyelid blepharoplasty: A new technique using nonablative radiofrequency on periorbital skin. Dermatol Surg. 2004; 30:125–129.

14. Ruiz-Esparza J, Gomez JB. The medical facelift: A noninvasive, nonsurgical approach to tissue tightening in facial skin using nonablative radiofrequency. Dermatol Surg. 2003;29:325–332.

15. Hsu TS, Kaminer MS. The use of nonablative radiofrequency technology to tighten the lower face and neck. Semin Cutan Med Surg. 2003;22: 115–123.

16. Iyer S, Suthamjariya K, Fitzpatrick RE. Using a radiofrequency energy device to treat the lower face: A treatment paradigm for a nonsurgical facelift. Cosmet Dermatol. 2003;16:37–40.

17. Ruiz-Esparza J, Gomez JB. Nonablative radiofrequency for active acne vulgaris: The use of deep dermal heat in the treatment of moderate to severe active acne vulgaris (thermotherapy): A report of 22 patients. Dermatol Surg. 2003;29:333–339.

18. Zelickson BD, Kist D, Bernstein E, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: A pilot study. Arch Dermatol. 2004;140: 204–209.