JRMS J Res Med Sci Journal of Research in Medical Sciences Journal of Research in Medical Sciences 1735-1995 1735-7136 Medknow Publications Pvt Ltd India JRMS-18-970 24523783 Original Article Patient satisfaction and efficacy of accent radiofrequency for facial skin wrinkle reduction Jaffary Fariba Nilforoushzadeh Mohammad A Zarkoob Hajar Skin Disease and Leishmaniasis Research Center, Dermatology Department, Isfahan University of Medical Sciences, Isfahan; Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, IranSkin Disease and Leishmaniasis Research Center, Dermatology Department, Isfahan University of Medical Sciences, Isfahan; Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, IranSkin Disease and Leishmaniasis Research Center, Dermatology Department, Isfahan University of Medical Sciences, Isfahan, Iran Address for correspondence:Mohammad Nilforoushzadeh, Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran Nilfroushzadeh@mui.ac.ir November 2013 18 11 970 975 2712013 472013 Copyright: © Journal of Research in Medical Sciences 2013

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background:

Radiofrequency (RF) is a new technique to treat facial wrinkles. This study was designed to assess the efficacy of Accent RF in wrinkle reduction of different areas of the face. Materials and Methods:

Patients with mild to severe facial wrinkles were treated with Accent using RF energies of 35-145 W. The average energy used in this study was 83.11 W. Patients received four subsequent weekly RF sessions. Wrinkle improvement was rated by two physicians comparing 6-month post treatment photographs with pretreatment photos. Moreover, patient satisfaction was assessed at 1 and 6 months after the last session of the treatment. Results:

A total of 45 women participated in this study. In terms of patient satisfaction one month after the last treatment, 8.9% of the patients declared their dissatisfaction, 53.3% were somehow satisfied, 33.3% were satisfied, and 4.4% were very satisfied. At 6 months, patient satisfaction was as follows: 4.4% dissatisfied, 31.1% somehow satisfied, 46.7% satisfied, and 17.8% very satisfied. Patient satisfaction 6 months after the last treatment was significantly higher than 1 month post treatment (P = 0.006). At 6 months, patient satisfaction was not more than 75% in any treatment areas of the face. Conclusion:

The results of this study suggest that Accent RF may be considered as a possible effective option for facial skin rejuvenation although its efficacy and safety needs to be evaluated further in randomized controlled trials.

Materials and Methods:

Patients with mild to severe facial wrinkles were treated with Accent using RF energies of 35-145 W. The average energy used in this study was 83.11 W. Patients received four subsequent weekly RF sessions. Wrinkle improvement was rated by two physicians comparing 6-month post treatment photographs with pretreatment photos. Moreover, patient satisfaction was assessed at 1 and 6 months after the last session of the treatment. Results:

A total of 45 women participated in this study. In terms of patient satisfaction one month after the last treatment, 8.9% of the patients declared their dissatisfaction, 53.3% were somehow satisfied, 33.3% were satisfied, and 4.4% were very satisfied. At 6 months, patient satisfaction was as follows: 4.4% dissatisfied, 31.1% somehow satisfied, 46.7% satisfied, and 17.8% very satisfied. Patient satisfaction 6 months after the last treatment was significantly higher than 1 month post treatment (P = 0.006). At 6 months, patient satisfaction was not more than 75% in any treatment areas of the face. Conclusion:

The results of this study suggest that Accent RF may be considered as a possible effective option for facial skin rejuvenation although its efficacy and safety needs to be evaluated further in randomized controlled trials.

Results:

A total of 45 women participated in this study. In terms of patient satisfaction one month after the last treatment, 8.9% of the patients declared their dissatisfaction, 53.3% were somehow satisfied, 33.3% were satisfied, and 4.4% were very satisfied. At 6 months, patient satisfaction was as follows: 4.4% dissatisfied, 31.1% somehow satisfied, 46.7% satisfied, and 17.8% very satisfied. Patient satisfaction 6 months after the last treatment was significantly higher than 1 month post treatment (P = 0.006). At 6 months, patient satisfaction was not more than 75% in any treatment areas of the face. Conclusion:

The results of this study suggest that Accent RF may be considered as a possible effective option for facial skin rejuvenation although its efficacy and safety needs to be evaluated further in randomized controlled trials.

Conclusion:

The results of this study suggest that Accent RF may be considered as a possible effective option for facial skin rejuvenation although its efficacy and safety needs to be evaluated further in randomized controlled trials.

Accent radiofrequency facial wrinkles patient satisfaction
</sec><sec><title>Introduction

Wrinkle reduction has increasingly become a common cosmetic procedure. Several methods are available for skin rejuvenation including dermabrasion, chemical peeling, autologous cultured fibroblasts transplantation, and ablative and nonablative laser therapy. 1,2 Despite the proven efficacy of these methods, their potential side effects and pitfalls such as pain, long recovery, and posttreatment downtime period has limited their application. 1,3 Cosmetic plastic surgery is the first choice treatment for skin laxity. However, for patients who do not want to undergo surgery or do not have time off work, monopolar radiofrequency (RF) is the/one of the best noninvasive alternative for soft tissue augmentation. 4,5 RF is an electromagnetic energy of 3 kHz to 300 MHz, which is similar to the optical energy that interacts with the tissue and produce heat. Despite lasers that target selective chromophore to produce heat, tissue resistance to electron movement in RF field is the source of heat generation in nonablative RF. 6,7,8 Induced dermal heating to the critical point of 65°C result in collagen contraction and promotes wound healing. 8 Selective dermal heating along with maintaining epidermal integrity could potentially decrease posttreatment side effects and minimize the recovery period. 9,10 Monopolar RF was approved by Food and Drug Administration (FDA) as a noninvasive treatment for periorbital wrinkles in 2002 and for removing facial wrinkles in 2004. 11 Accent is a RF system with both monopolar and bipolar devices and got FDA approval for treating wrinkles in 2007. 11 RF wave penetrate deeply up to 20 mm with monopolar headpiece and 2-4 mm by bipolar headpiece. 12,13 Local anesthesia is required with both hand pieces. The average treatment sessions were 1-2 for monopolar and 6-8 for bipolar mode. 14 Although previous studies have shown RF as a safe and effective method for reducing wrinkles it could not be considered as nonsurgical lifting for skin rejuvenation as presented in misleading promotions by some physicians. 13 Published clinical evidence documents monopolar RF for skin tightening and treating mild to moderate wrinkles 9 and similar to any other cosmetic procedure it has its specific indications, efficacy, problems, and limitations. Careful patient selection and real expectation are the key points in a successful treatment. 15,16

The optimum RF parameters is a controversial issue despite the considerable evidence of its efficacy and safety in removing periorbital, chin and neck wrinkles and eyebrow lifting. 17,18,19,20 Some authors have reported high patient satisfaction for RF treatment but the overall impression of available reports is that the results of nonablative RF are neither predictable nor significant. 5,21,22,23,24,25 Subjective nature of the major outcome measure of these studies questions the validity of their results.

The main objective of this study was further assessment of Accent RF and its parameters for treatment of skin laxity and reducing wrinkles in Iranian patients.

Materials and Methods

A total of 45 patients with facial wrinkles were recruited from Jordan dermatology Clinic in Tehran and Novin Laser, Isfahan for this study. All patients signed informed consent form after complete explanation of the study design. Patients that meet any of the following conditions were excluded from the study: History of taking oral isotretinoin, Botox injection, injection of any filling agent, laser, chemical peeling, dermabrasion or cosmetic surgery within last 12 months for perioral area and within last 6 months for the rest of the face, pregnancy, lactation, history of severe cardiac disease, collagen and vascular disease, immunosuppressive disease or taking immunosuppressive drugs, patients with history of a dermatologic disease or active dermatologic problem such as herpes, history of keloid, having pacemaker or any metal pieces in body. 11,26

Baseline photographs were taken from all patients using Canon, Digital camera, 8.3 Mega pixels, 6015. All photos were taken by the same person using the same angle and distance of the light source.

Patients received Accent RF (Accent, Alma Lasers US 2007, monopolar or bipolar mode) for 4 weekly sessions in at least one anatomic area of the face (frontal, periorbital, perioral, laugh lines, cheeks, or chin). Each treatment area on the face was about 30 cm 2 and 3 × 2 cm in periorbital area.

For all areas of the face, 5-6 passes of 30 seconds were performed except for the periorbital area, which was limited to 4 passes. In each session, two initial passes of 30-60 seconds were made to heat the area to 40°C, and then another 2 passes of 30 seconds were applied to maintain the tissue temperature in 40-44°C. Energy level of initial passes was 80 W for monopolar handpiece, 100 W for bipolar handpiece, and 74 W for periorbital area. Five circular movements were made during each 30 second pass of the handpiece. Follow up visits were done 1 and 6 months after the last session and all patients were asked and assessed for any adverse effects.

Follow up photography was taken 6 months after the last session. Wrinkle improvement was graded by three blinded assessor physicians comparing baseline and 6-month posttreatment photographs (0 = <25%, 1 = 25-50%, 2 = 51-75%, 3 = >75%). 26

Patients satisfaction 1 and 6 months after the last treatment session was evaluated using a questionnaire with 4-point Likert scale (1 = Not satisfied, 2 = fairly satisfied, 3 = Satisfied, 4 = Very satisfied). 26,27

Mean percentage agreement among the three physicians was assessed. 28 Data was analyzed by SPSS software version 12, SPSS Inc. using chi-square, Wilcoxon and Spearman correlation tests. This was a pilot clinical trial with SDRLC research project No. 8620.

Results

A total of 45 patients (42 women, 3 men) with age range of 31-65 years (mean = 45.62) participated in this study: 31-40 years, 28.9%; 41-49 years, 42.2%; 50-58 years, 24.4%, and 59-68 years, 4.4%. About 70% of the patients were aged over 50 years.

A total of 21 patients (46.7%) were Fitzpatrick skin type III and 24 had type IV. Other characteristics of the patients are summarized in Table 1.{Table 1}

A total of 832 RF sessions were performed on 213 anatomical areas of the face in 45 treated patients.

The mean energy level was 35-57 W in 293 (34.4%), 58-79 W in 25.4% of the sessions, 80-101 W in 32.8%, 102-123 W in 6%, and only 0.5% of the sessions were performed with the range of 124-145 W.

Fourteen patients were treated in the frontal area for 176 sessions with the energy level of 44-124 W. RF with the rage of 35-56 W was done on periorbital area of 42 patients. There was a total of 156 sessions on laugh area of 39 patients, 172 sessions on cheek area of 43 patients, and 176 sessions on chin area of 44 patients with the energy level of 45-145 W in all these three areas Table 2.{Table 2}

The applied mode of Accents RF is summarized in Table 3. {Table 3}

Table 4 shows assessment of facial wrinkles by blinded physicians. None of the treated facial areas achieved wrinkle improvement >75%.{Table 4}

Mean percentage agreement for physician assessment was 33.4%, 35.5%, 37.7%, 41.3%, 39.2%, and 38.4% for forehead, orbit, cheek, chin, nasolabial fold and full face respectively.

Table 5 shows patient satisfaction 1 and 6 months posttreatment. Patients were significantly more satisfied of RF results at 6 months posttreatment than 1 month (Wilcox test, P = 0.006). There was no relationship between patient satisfaction and physician clinical assessment at 6-month posttreatment (Spearman test, r = 0.05, P = 0.73).{Table 5}

Patients satisfaction for full face improvement at 6 moths was more than the physician assessment with no significant relationship (Spearman test, correlation coefficient = 0.05, P = 0.73). There was no significant relationship between physician′s assessment of improvement and age and also there were no relationship between the energy level and patients or physicians opinion (P > 0.05).

Adverse effects of Accent therapy one month after the treatment were erythema (11.1%), erythema and edema (86.7%), edema and ecchymosed (2.2%). There was no report of fat atrophy in patients of this study. There was no side effect 6 months after the last session.

Discussion

Skin rejuvenation has shifted from ablative methods toward fractional ablative and nonablative procedures during past 15 years. RF is a safe effective procedure for reducing skin wrinkles. 29 Collagen repair and realignment is a possible mechanism of tissue tightening followed by RF treatment. Assessment of RF treated skin shows that heat generated by tissue′s natural resistance to RF waves induces changes in collagen fibrils and an increase in expression of messenger RNA (mRNA) for collagen type I. 30 Clinical results of tissue tightening by nonablative RF was first reported in periorbital area. Different results have been reported for its efficacy such as skin tightening in 14 out of 15 patients treated with RF in lower one-third of the face, and modest wrinkle improvement with high patient satisfaction in laugh lines and achieving significant improvement of skin laxity in 70% of the treated patients 3 months posttreatment. 19,31,32,33

The results of this study were different in terms of wrinkle improvement and patient satisfaction from similar studies.

For physician assessment, Friedman et al.5 reported 26-50% wrinkle improvement in 96% of the treated patient and >75% improvement in 19% of the patients. In cheek area, 42% of patients achieved 51-75% and 17% more than 75% improvement of wrinkles. In our study neither in the same area nor in periorbital and frontal areas the improvement was not more than 50%.

There was no wrinkle improvement of >75% in none of the treated areas of this study. Several factors such as energy level, number of passes, interval between treatment sessions and mode of RF could be involved in different achieved responses in the rate of wrinkle improvement and patient satisfaction. Applied energy level in the Friedman 2007 study for monopolar RF was similar to previous studies. 19,32,33,34 The range of applied energy in our study was 60-121 W for monopolar RF and 35-145 W for bipolar RF compared with 80-140 W and 50-70 W in the Friedman study, respectively. In our study both monopolar and bipolar RF were used at laugh lines while in the Friedman et al. study, only monopolar handpiece was used in this area. For cheek area, in 91.27% of patients (157/172) bipolar mode was used compared with monopolar RF applied in the Firedman et al. study, with a modest more range of energy (100-140 W versus 60-106 W in our study. In our study, the range of applied energy in periorbital and chin area was less than the Friedman et al. study for monopolar mode and more for bipolar mode. Most of the sessions in chin area and laugh lines in our study were bipolar (171-176 W and 107-156 W, respectively). In contrast to the results of our study, Hsu and Kaminer reported a significant relationship between energy level and clinical response. 35

In the Friedman study, RF therapy was initiated with 20 seconds (per pass) × 120 W for monopolar and 20 seconds (per pass) × 60 W for bipolar mode and was continued with 20 seconds (per pass) × 100 W, and 20 seconds (per pass) × 50 W, respectively. In our study both modes were initiated with 80-100 W, 20 seconds and the maintenance energy level was selected based on the treatment area. Average number of passes in the Friedman study was 5 for all facial areas compared with 5.6 passes used in our study for all facial areas except for periorbital area (mean = 4 passes). Some studies have estimated 9-10 passes to achieve clinical improvement. 36,37 The most observed difference in clinical results of our study and the Friedman et al. study were in frontal, periorbital, and cheek areas. Possible explanations for this difference are higher energy level and application of monopolar mode in cheek area, higher energy level in periorbital area, application of both modes in frontal area, and different duration of outcome assessment (6 months versus 1 month posttreatment in the Friedman study). Previous studies have shown greater clinical results for RF in young patients. Alster and Tanzi reported less clinical improvement in patients >62 years compared with >46 years for the Friedman study. 6,18 However, the results of our study did not confirm this finding.

Greater patient satisfaction 6 months posttreatment versus 1 month in our study may be attributed to induction of fibroblast and continued collagen synthesis. Significant pain and fat atrophy is reported following RF performance with a similar device. 38 No fat atrophy was observed in our patients similar to the Friedman results. Both RF modes in our study were performed without using local anesthetic and it was considered as a moderate, tolerable discomfort by the patients. Although the efficacy of RF for facial wrinkle improvement is confirmed by the recent published reviews, more careful scrutiny on the included trials of these reviews reveals that these reviews mostly have summarized company-sponsored trials. 39 Other studies have shown that a expected post-RF clinical improvement in 80-85% of the treated patients is a modest skin tightening and some patients may experience no benefit at all. 5,40,41

Few experiences have examined RF-induced histological changes. 42 It is not clear how long heat-induced collagen changes will persist after RF treatment. Such histological changes may not be consistent in older patients with advanced photo aging skin problems. Currently, the clinical consensus on optimum RF parameters to achieve the best clinical results is not available. 37 The results of our study could be considered as one step in the chain of trials to achieve this objective.

As an overall conclusion several aspects needs to be included in initial RF consultation sessions. RF should be introduced to the patients as a technology to reduce - and not remove - fine facial wrinkles, with less efficacy and side effects than ablative procedures. 26,40,41 The best candidates for this procedure are young patients with modest facial skin sagging. The immediate results after RF are due to collagen contraction and edema which are temporary and there are modest final permanent results. 42,43 Adequate training programs for physicians and careful patient selection are recommended for perfect performance and minimizing the side effects. 36 Comprehensive consultation sessions, honest patient-physician relationship, and real expectations will further guarantee the successful results.

It should be emphasized that the efficacy of nonablative methods (including RF) cannot be compared with ablative procedures. Nonablative methods are good choices for the patients who want to minimize posttreatment pain and downtime period. Combination treatment of RF and other procedures such as Botox, filling agents and fractional laser is increasingly used for skin rejuvenation. 41,43

This was a pilot clinical study of Accent efficacy and safety for facial skin wrinkles and all its limitations including small sample size and lack of standard group should be considered in any interpretation of the results. Randomized clinical trials comparing the effect of Accent RF with standard comparators for facial wrinkle reduction and evaluation of optimum contributing factors such as mode, energy, pass and number of treatment sessions should be further designed following such pilot studies.

Acknowledgment

This study was approved by SDLRC ethical committee, Isfahan University of Medical Sciences, Isfahan, Iran. The authors would like to thank all SDLRC affiliated physicians and staff including H. Heidari for data entry and Dr. M. Hosseini for his comments in data analysis. The authors do not have any conflict of interest.

Alam M Dover JS Arndt KA Energy delivery devices for cutaneous remodeling: Lasers, lights, and radio wavesArch Dermatol 2003 139 1351 60 Goldberg DJ Cutler KB Nonablative treatment of rhytids with intense pulsed lightLasers Surg Med 2000 26 196 200 Narurkar VA Lasers, light sources, and radiofrequency devices for skin rejuvenationSemin Cutan Med Surg 2006 25 145 50 Burns JA Thermage: Monopolar radiofrequencyAesthet Surg J 2005 25 638 42 Friedman DJ Gilead LT The use of hybrid radiofrequency device for the treatment of rhytides and lax skinDermatol Surg 2007 33 543 51 Sadick NS Makino Y Selective electro-thermolysis in aesthetic medicine: A reviewLasers Surg Med 2004 34 91 7 Fitzpatrick R Geronemus R Goldberg D Kaminer M Kilmer S Ruiz-Esparza J Multicenter study of noninvasive radiofrequency for periorbital tissue tighteningLasers Surg Med 2003 33 232 42 Bogle MA Ubelhoer N Weiss RA Mayoral F Kaminer MS Evaluation of the multiple pass, low fluence algorithm for radiofrequency tightening of the lower faceLasers Surg Med 2007 39 210 7 Abraham MT Mashkevich G Monopolar radiofrequency skin tighteningFacial Plast Surg Clin North Am 2007 15 169 77,v de Felipe I Del Cueto SR Pérez E Redondo P Adverse reactions after nonablative radiofrequency: Follow-up of 290 patientsJ Cosmet Dermatol 2007 6 163 6 Alexiades-Armenakas M Dover JS Arndt KA Unipolar radiofrequency treatment to improve the appearance of celluliteJ Cosmet Laser Ther 2008 10 148 53 Alexiades-Armenakas M Dover JS Arndt KA Unipolar versus bipolar radiofrequency treatment of rhytides and laxity using a mobile painless delivery methodLasers Surg Med 2008 40 446 53 Rinaldi F Laser: A reviewClinics in Dermatology 2008 26(1) 591 601 Zdinak LA Summerfield ME Nonablative skin therapiesOphthalmol Clin North Am 2005 18 237 48 DeHoratius DM Dover JS Nonablative tissue remodeling and photorejuvenationClin Dermatol 2007 25 474 9 Ruiz-Esparza J Gomez JB The medical face lift: A noninvasive, nonsurgical approach to tissue tightening in facial skin using nonablative radiofrequencyDermatol Surg 2003 29 325 32 Alster TS Tanzi E Improvement of neck and cheek laxity with a nonablative radiofrequency device: A lifting experienceDermatol Surg 2004 30 503 7 Iyer S Suthamjariya K Fitzpatrick RE Using a radiofrequency energy device to treat the lower face: A treatment paradigm for a nonsurgical faceliftCosmet Dermatol 2003 16 37 40 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 faceDermatol Surg 2004 30 922 8 Alexiades-Armenakas MR Dover JS Arndt KA The spectrum of laser skin resurfacing: Nonablative, fractional, and ablative laser resurfacingJ Am Acad Dermatol 2008 58 719 37 Carruthers J Carruthers A Shrinking upper and lower eyelid skin with a novel radiofrequency tipDermatol Surg 2007 33 802 9 Fisher GH Jacobson LG Bernstein LJ Kim KH Geronemus RG Nonablative radiofrequency treatment of facial laxityDermatol Surg 2005 31 1237 41 Bassichis BA Dayan S Thomas JR Use of a nonablative radiofrequency device to rejuvenate the upper one-third of the faceOtolaryngol Head Neck Surg 2004 130 397 406 Atiyeh BS Dibo SA Nonsurgical nonablative treatment of aging skin 2009 283 94 Hruza G Taub AF Collier SL Mulholland SR Skin rejuvenation and wrinkle reduction using a fractional radiofrequency systemJ Drugs Dermatol 2009 8 259 65 Elsaie ML Choudhary S Leiva A Nouri K Nonablative radiofrequency for skin rejuvenationDermatol Surg 2010 36 577 89 Yeung CK Chan NP Shek SY Chan HH Evaluation of combined fractional radiofrequency and fractional laser treatment for acne scars in AsiansLasers Surg Med 2012 44 622 30 Simplistic Example Coding for Inter-rater Agreement Available from: http://wwwpdf [Last accessed on Jan ]. 3]. Available from: http://wwwbwgriffincom/gsu/courses/edur9131/content/InterRater_nominal_codespdf [Last accessed on 2013 Jan 13] Zelickson BD Kist D Bernstein E Brown DB Ksenzenko S Burns J Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: A pilot studyArch Dermatol 2004 140 204 9 Dover JS Zelickson B Results of a survey of 5,700 patient monopolar radiofrequency facial skin tightening treatments: Assessment of a low-energy multiple-pass technique leading to a clinical end point algorithmDermatol Surg 2007 33(8) 900 7 Jacobson LG Alexiades-Armenakas M Bernstein L Geronemus RG Treatment of nasolabial folds and jowls with a noninvasive radiofrequency deviceArch Dermatol 2003 139 1371 2 Alexiades-Armenakas M Rhytides, laxity, and photoaging treated with a combination of radiofrequency, diode laser, and pulsed light and assessed with a comprehensive grading scaleJ Drugs Dermatol 2006 5 731 8 Dover JS Zelickson B; 14-Physician Multispecialty Consensus Panel Results of a survey of 5,700 patient monopolar radiofrequency facial skin tightening treatments: Assessment of a low-energy multiple-pass technique leading to a clinical end point algorithmDermatol Surg 2007 33 900 7 Hsu TS Kaminer MS The use of nonablative radiofrequency technology to tighten the lower face and neckSemin Cutan Med Surg 2003 22 115 23 Biesnman BS Controversies and Conversations in Laser and Cosmetic Surgery Dover JSIn 2005 nver, CO Wirtzer A Nonablative radiofrequency for skin rejuvenationDermatol Surg 2010 36 2083 4 Ee HL Barlow RJ Lasers, lights and related technologies: A review of recent journal highlightsClin Exp Dermatol 2007 32 135 7 Ruiz-Esparza J Nonablative radiofrequency for facial and neck rejuvenation.A faster, safer, and less painful procedure based on concentrating the heat in key areas: The ThermaLift conceptJ Cosmet Dermatol 2006 5 68 75 DeHoratius DM Dover JS Nonablative tissue remodeling and photorejuvenationClin Dermatol 2007 25 474 9 Weiss RA Weiss MA Beasley KL Munavalli G Our approach to non-ablative treatment of photoagingLasers Surg Med 2005 37 2 8 Elsaie ML Cutaneous remodeling and photorejuvenation using radiofrequency devicesIndian J Dermatol 2009 54 201 5 Yu CS Yeung CK Shek SY Tse RK Kono T Chan HH Combined infrared light and bipolar radiofrequency for skin tightening in AsiansLasers Surg Med 2007 39 471 5 Christiansen D Stebbins W A guide to safety in dermatologic cosmetic procedures: Avoidance and management of common pitfalls and perils.Curr Derm Rep 2013,2:125-34http://www A guide to safety in dermatologic cosmetic procedures: Avoidance and management of common pitfalls and perils Curr Derm Rep 2013,2:125-34 http://wwwncbinlmnihgov/pubmed/17659587