RF Treatments: Hope or Hype?

Many new devices have appeared on the market that utilize radiofrequency (RF) energy to effectively tighten and rejuvenate the skin. The first groundbreaking radiofrequency device was the Thermage. Following in Thermage’s success, a whole range of other radiofrequency devices have sprung up, Some with notable success, others delivery results no better than a facial. Here are top picks of radiofrequency devices that have been clinically proven to tighten skin.

How does RF (radiofrequency) work?

mechanism of action of radiofrequency skin tightening


Radiofrequency energy uses the tissue’s resistance within the various layers of the skin to transform the RF energy given to the skin into thermal energy. Many considerations are required for there to be successful transfer of the RF energy into thermal energy, including the size and depth of the tissue being treated, as one needs to consider the tissue impedance of the skin being treated. Since RF energy produces an electrical current instead of a light source, tissue damage can be minimized, and epidermal melanin (pigment) is not damaged either. With this knowledge, RF energies can be used for patients of all skin types – that is, it is color blind and allows for different depths of penetration based on what is to be treated, allowing for ultimate collagen contraction and production of new collagen.

Why the device matters in radiofrequency treatments is because some of the low end versions do not actually reach deep enough to effect true skin tightening changes. Secondly, as radiofrequency causes heating of the skin, there must be an effective surface cooling to protect skin surface from burning. That explains why in some low powered machines, the radiofrequency is underpowered. Conversely, if the power were to be cranked up, surface burning of the skin may result as they do not have a powerful enough surface cooling device.

Are all RF devices the same?

The first and still widely used device is known as the Thermage. It uses monopolar RF energy, in that energy runs from the treatment tip through the skin to a grounding pad on a distant part of the skin. In the original clinical trial with the Thermage, Fitzpatrick et al. evaluated 86 patients who received a single treatment with the device on the forehead and temple regions.[4] They found an 83.2% improvement of at least one point in the Fitzpatrick wrinkle score. They also found, on average, an eyebrow lift of 0.5 mm in 61.5% of the patients at the end of their study period. The patient satisfaction rate was 50% and adverse events, including erythema (36%) and edema (14%), were found to occur and to resolve within a reasonable time period. Burns were noted in 0.4% of the patients. A US FDA approval for noninvasive treatment of the periorbital rhytids came in 2002, and for the full face in 2004.

Latest versions of Thermage utilizes a Comfort Pulse Technology™ (CPT) handpiece that uses vibration to make the procedure even more comforting.With Thermage, one finds that when the procedure works, it continues to work well over time, which was also borne out in the study-survey performed by Dover et al. Thermage is the prototype device that all other devices are compared with and compare themselves to. It is still going strong, and has a large and loyal following. A clinical example is shown in Figure 1.

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Clinical example of Thermage® post-treatment. Photos courtesy of Solta Medical.


The second monopolar RF device developed is known as the Accent XL® (Alma Lasers, IL, USA). In this device, there is a monopolar treatment head, known as a unipolar device. The unipolar device has the grounding plate within the treatment head – which means there are no disposable tips to this device, compared with the disposable Thermage tip. In their article, Friedman and Gilead found that the majority of the patients treated with the Accent XL noted an improvement after two to six treatments of between 50 and 75%.[9] The device was well tolerated and adverse events were not significant.

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Clinical example of Accent® treatment immediately after one treatment.   J. Clin. Aesthet.Dermatol. 3(5), 36–41 (2010).


Another bipolar RF device, known as the Aluma® (Lumenis Inc., CA, USA), combined bipolar RF with a vacuum apparatus. In their study, Gold et al. demonstrated that with this device, skin laxity and wrinkles could be treated in an effective manner.[10] In this study, 46 individuals underwent treatment every other week for a total of eight treatments – and were then followed for 6 months following the last treatment. An average of a 2-point reduction in the elastosis scale was observed in the majority of the patients treated. Overall skin appearance and improvement in skin texture was also observed in all of the patients treated. The treatments were carried out with minimal discomfort and adverse events were not significant. Although this device produced some very nice clinical results, it is not currently available in the US market.

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Aluma® (Lumenis Inc., CA, USA)


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Are there other RF devices on the market?

There are a huge range of other RF devices on the market; many of the lower end versions such as the Exilis deliver poorer outcomes. Usually used in salons, it is often sold as a package of several sessions, but with questionable efficacy even at the end of the course of treatment. However, many of the lower end RF may serve as good adjuvant to facials as their more superficial heating depth can provide some transient improvement in skin tone (a few days) which may suffice for someone looking for a short term type of treatment. These are probably best considered as a ‘facial” than a long term skin tightening investment.

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