The natural evolution of microneedling as a primary tool in dermatologic and energy-based applications is based on its unique physical attributes. Historically, microneedling was performed as a standalone treatment for scarring or texture irregularities using plain needles that were stamped, rolled or mechanically inserted at hundreds of perforations per second1. Over the last nine years, technique and technology innovations have allowed topical agents such as cosmeceuticals, medications, biologics and growth factors to be “infused” into the dermis during treatment, as well as delivery of radiofrequency (RF) energy through desired tissue layers, for more than just controlled injury or perforation. The cutting-edge precision, energy delivery techniques and needle design have facilitated an evolution that allows us to treat novel issues: from eye bags to jowl sags.
Why “Inject” RF?
Consistently, in the shadows of laser options, when choosing between energies for rejuvenation or restoration, the second-best contender has been RF. However, with recent technological advancements that overcome some of the variability in biologic impedance, and a more evidence-based understanding of tissue interactions with RF2, clinicians can access new opportunities for flexible treatment options. When injecting energy (E = Watts x Time / cm2), variables to consider include: output in watts, time (pulse width), surface area (cm2), wave form, electrical conductivity, depth and size of target, and electrode shape.
The advanced approaches to RF microneedling evolved from a two-dimensional, broad area of treatment with variable efficiency and limited needle design, to a more three-dimensional approach with precision. This requires sufficient energy to melt adipose tissue and needle designs that can reach deep into the subdermis. Conceptually, it is about delivering the adequate “dose” of energy required to treat a volume of tissue in multiple planes to maximize skin contraction. The most surface contraction occurs from treating (heating) the septal connective tissue and the deep fascia3.
Figure 1 represents a new option to achieve this combination of precision and deep thermal coagulation. Primarily monopolar and using a single or triple needle (Figure 2), this device features a unique needle design and thoughtful insulation, allowing lipolysis of small aliquots of adipose tissue and contraction of the fibroseptal network, often with a palpable and visual change on the table at the time of treatment (Figure 3).
The patient in Figure 4 is a 49-year-old woman with heavy nasolabial fold, buccal fat and jowl. The goal of treatment was to reduce volume in the areas we wanted to sculpt, thereby creating “negative” space. Topical anesthetic was applied 45 minutes prior to treatment and regions were marked. The patient was cleansed (alcohol and lasercyn-stabilized hypochlorite), and regions were locally infiltrated with 1% lidocaine with epinephrine and bicarbonate buffer, using a half-inch 30-gauge needle (alternatively, a microcannula can be used). The volume of anesthetic was less than 3 cc per region, delivered intradermally (or in the very superficial subcutaneous), and in small amounts, to minimize the possibility of muting RF through oversaturation, and to reduce edema.
Areas were treated via a single F1A needle, with a vertical insertion at moderate power level 10, 400 ms pulse width, with the number of pulses/injections totaling approximately 200 per area (depending on the size of the region). Areas with more substantial volume were treated with a secondary pass using the 4 mm F3A triple needle, at moderate power level 11, 400 ms pulse width, and approximately 100 pulses per area. Ice and pressure were applied as each region was completed, and a bandage was applied to treated areas (Duoderm, extra thin). Patients kept areas covered with the bandage for at least 24 hours until naturally loosened. Hypoallergenic moisturizer and physical sunblock were used for five to seven days post treatment. Patients had mild swelling for a week, with the post treatment photo in Figure 4 demonstrating volume reduction and contraction at one month.
Treatment of eye bags employs a similar technique, using minimal local anesthetic (less than 1 cc per eye), an F1A single needle only and approximately 10-30 pulses/injections per orbital fat pad, depending on the size and degree of herniation. Tangential insertion of the same single needle can achieve a superficial ablation or coagulation (dermal-subcutaneous junction) for additional contraction if needed. The transcutaneous ligaments are incorporated with this approach and can provide improved laxity (versus laser-based treatments that do not).
The best outcomes come from combining precision RF treatment to reduce and tighten, with global treatment to address different planes of energy delivery – from deep subcutaneous to the superficial dermis. Options include newer multi-array needles (25 - 49 microneedles) that deliver monopolar or bipolar energy, and utilize insulated or non-insulated needles, to thoughtfully place energy and zones of coagulation to truly move tissue. It appears that the wound geometry of non-insulated, gold needles delivers more contraction over large areas, with faster treatment and minimal downtime.
Finally, from a more regenerative aesthetic perspective, the delivery of energy in a mindful, three-dimensional “layering”, is only as good as the health of the tissue and the patient. Looking ahead, the next advancement integrates the use of novel precious metal topicals, growth factor based products (PRP, PRF, Exosomes) and nutritional support pre or post-treatment, to enhance impedance and predictability, reduce downtime and improve clinical outcomes.
About the authors
JD McCoy, NMD
Aesthetic medicine is the art of cosmetic rejuvenation using less-invasive medical treatments, so Dr. McCoy understands the importance of being on the cutting edge when it comes to advancing technology and techniques used in less invasive cosmetic medicine. Dr. McCoy received his doctorate in Naturopathic Medicine at the Canadian College of Naturopathic Medicine. He completed an internship in internal medicine in Hawaii, and began specialized training, certification and externship in cosmetic and light-based therapies. Dr. McCoy has devoted his specialization, passion and his entire practice to the art of less invasive cosmetic rejuvenation, weight management and natural bio-identical hormone therapy since 2003.
Ms. Barr is a seasoned innovator and recognized expert in medical aesthetics, dedicating the last decade to advancing clinical outcomes and educating the market. Ms. Barr is an active clinician, and her hands-on experience combined with a versatile background in medical sciences, engineering and sales development has provided her opportunities to impact several leading manufacturers such as Zeltiq Aesthetics, Syneron Candela, Lumenis, Venus Concept, Agnes Medical and AdvaLight. She is the author of numerous industry-wide adopted protocols and her work has improved concept and design of multiple technologies and launched brands with elevated safety and integration capacity. She is an internationally sought-after consultant, and the founder of Med Aesthetics 360 & Experiential Learning Center in Boulder, Colo., where physicians and industry leaders evolve their understanding of technologies through clinical immersion training.
References:
1. Mujahid N, Shareef F, Maymone MBC, Vashi NA. Microneedling as a Treatment for Acne Scarring: A Systematic Review. Dermatol Surg. 2019 Jul 23.
2. Duncan D. Nonexcisional Tissue Tightening: Creating Skin Surface Area Reduction During Abdominal Liposuction by Adding Radiofrequency Heating. Aesthetic Surgery Journal. 2013 Nov; 33(8): 1154-1166.
3. Malcolm P, Blugerman G, Kreinel M, Mulholland RS. Three-Dimensional Radiofrequency Tissue Tightening: A Proposed Mechanism and Applications for Body Contouring. Aesthetic Plast Surg. 2011 Feb; 35(1): 87–95.
Editor's note: Agnes is FDA approved with a general clear- ance and no indication for any specific procedures. The use of Agnes for any aesthetic procedures in the U.S. is considered an off-label procedure.