6 j
zones include treatment of the periorbital area (crow's feet) Radiofrequency devices are capable of tightening skin and improving contours. The physician must analyze the three-dimensional facial structure of the patient to assess those areas that would benefit most from tightening. Typically, this would include the forehead/
brow area, as well as the lower cheek, jawline, and sub- mental region
64
L a s e r s a n d L i g h t s V o l u m e l l
. Preoperative setup
G E N E R A L
Preoperative photographs are taken. For the Galaxy system, all areas to be treated are covered with a thick layer of anesthetic cream (LMX 50/o cream, Ferndale Lab- oratories, Inc , Ferndale, MI) with or without occlusion with plastic wrap to create mild epidermal anesthesia and hydration Some physicians also apply anesthetic cream prior to Thermacool After approximately t hour the cream is removed, and the area is cleansed with alcohol wipes, moist gauze, as well as dry gauze. It is essential to remove all of the topical anesthetic cream The newer RF device Accent (Alma lasers) does not require topical anesthetic.
T H E R M A C O O L
For the ThermaCool system, the treatment grid is then applied with the ink side on the skin and the use of alcohol swabs to the back side ofthe grid paper, thoroughly wetting the paper. This allows transfer of the ink to the area to be treated The grid is used to ensure even placement of the treatment pulses and to prevent overlap, which could lead to excessive heat and epidermal or dermal injury The adhesive return pad is applied to the patient's left flank to ensure a travel conduit for the RF energy and to complete the circuit It is important that the return pad be placed in this same location on all patients since impedance read- i n g s c a n c h a n g e w h e n t h e p a d i s m o v e d to o t h e r l o c a t i o n s (personal communication, Thermage, Inc.). The return pad is attached to the machine, and a new treatment tip is placed into the handpiece
GALAXY
For the Galaxy system, no grounding pad is needed, as this is a bipolar system. Aqueous gel is applied. The Polaris handpiece is applied in successive passes that are perpen- dicularly oriented to each other The first pass is applied in parallel adjacent pulses across the skin surface at the parameters aforementioned The next pass is applied perpendicular to the first pass, across the entire skin surface. For the subsequent pass, the first pass orientation is repeated. The clinical endpoint of erythema rs achieved
A C C E N T
For the Accent system, mineral oil is applied. The hand- piece is kept mobile throughout the treatment. The hand- piece is moved across the patient's skin in regular, uniform, or circular movements, spanning the entire surface area.
The clinical endpoint of erythema and a surface tempera- ture of 40-42'C is attained
o Anesthesia alternatives
Due to the discomfort with the Thermage procedure at higher settings, multiple passes at lower settings have
become the current recommendation The challenge with pain control while heating areas of deep dermis, and potentially subdermal structures, is that topical anesthet- ics do not typically penetrate to that depth Therefore, adjunctive measures have been utilized to enhance patient comfort and to relieve anxiety caused by the deep heating sensatlon.
Nerve blocks are theoretically useful, particularly on the forehead. However, users are cautioned that complete elimination of pain feedback from the patient as a data point for energy adjustment may put the patient at risk of thermal injury. Since pain perception can help the physician understand when thermal injury is hign, nerve blocks are not recommended. Rather, patient feedback of pain perception on a l-10 scale is used Treatment is titrated to a maximum pain of 5 out of 10. Although injectable local anesthesia can eliminate pain, it also adds a conductive fluid to the subdermal environment, which in turn reduces tissue impedance. This iatrogenic altera- tion in tissue impedance can have negative effects on both patient outcomes and predictability. Until further study is undertaken to predict its effects, it is not recommended as a form of anesthesia.
For these reasons, physicians have turned to various forms of sedation to improve patient comfort. Complete general anesthesia or intravenous conscious sedation com- pletely take patient pain feedback out of the equation and are not recommended. Rather, pain control options using oral and intramuscular medications seem to dramatically improve patient comfort during the procedure, yet still enable some patient feedback. In practice, physicians use various combinations of medicatrons includins oraL diaz- epam, lorazepam, triazolam, oxycodone, ut *"11 as intra- muscular meperidine, hydroxyzine, and butorphanol The authors have developed a combination approach that has substantially improved patient tolerance of the procedure.
Patients are given I mg of lorazepam oraily upon arrival.
Fifteen minutes before the procedure is to begin, patients are given meperidine 75 mg and hydroxyzine 25 mg intra- muscularly A second I -mg dose of lorazepam is given subiingually at the start of the procedure if patients are stil1 uncomfortable.
Performing the first 20-30 cases without oral, intra- muscular, or topical anesthesia is a useful iearning tool.
This approach teaches the physician how to manage dif- ferent areas of the face, as well as different pain percep- tions from patient to patient while strictly adhenng to the 5 out of 10 pain guidelines Once the doctor is experi- enced in using the ThermaCool system, pain controi can be expanded by utilizing sedating medications.
The combination RF and diode or intense pulsed light flPL) system (Galaxy, Syneron) does not require systemic analgesia as the discomfort is well controlled with topical anesthetic creams Topical lidocaine and prilocaine cream (EMt-{) is applied for I hour prior to treatment and is adequate for pain control.
An advantage of the newer mobile RF device Accent fAlma) is that it is painless and no anesthesia is required.
6 5
The tip provides cooling and the mobile nature of energy delivery precludes the need for pain control.
o Genera[ treatment principles
T H E R M A C O O L
Eariy treatments [2001-2002) with the Thermage device were done with a single pass at relatively low fluences using the so-called 'slow
tip.' As the understanding of RF tissue physics improved, so did the physician comfort level with increasing both fluence per pulse and the number of passes over the same tissue area. A key break- through seems to have occurred with the addition of selec- tively placed second, third, and even fourth through length passes to the treatment algorithm. \A4ren a single pass is used, many patients will benefit from treatment Adding multiple passes in selected lax areas appears to yield greater benefit, sometimes visible at the time of treat- ment. Rarely are any immediate benefits seen after one pass, but they are almost routinely seen when multiple passes are employed (Box +.2).
A second key breakthrough has been the use of lower fluences with multiple passes to minimize discomfort and maximize clinical results Lower fluences correlate with less pain, but by delivering multiple passes to a given area, total energy delivered actually increases. This has resulted in both rmproved results, and importantly, increased pre- dictability. Thus, the population of patients who might benefit from the Thermage procedure has expanded considerably with these additions to the treatment algorithm
GALAXY
For the Galaxy [SyneronJ system, topical anesthesia is adequate. Topical EMIA for I hour with or without occiusion provides acceptable pain control in the vast majority of patients.
A C C E N T
For the Accent (Alma) system, no pain control is neces- sary as the procedure is painless.
.F First Pass
353 0 355 5 central forehead 353 0-355 5 cheeks and neck 3 5 2 5 3 5 3 0 t e m p l e s .i" Second Pass
353 0-355 5 central forehead 353 0-355 5 cheeks, jawline and neck
* Third Pass
353 0-354 5 central forehead, cheeks, submental, and j a w l i n e
* Fourth and Fifth Pass
353 0-354 5 jawline, jowls, and submental
Skin Tightening with Radiofrequency
. Periorbital rejuvenation
T H E R M A C O O L
Treatment for periorbital improvement should extend across the entire forehead, down to the temples and the crow's feet area. Initially, a 'fine
tune' series of 2-3 treat- ment firings is performed with the ThermaCool to tune the device to the patient's skin. A generous amount of coupling gel is applied to ensure complete contact between the treatment tip and the skin. The gel can be added or reap- plied as needed during the treatment session After the fine tuning, actual treatment firings may begin after choosing the energy level. With the 3-cm2 treatment tip and a typical setring of 354.0-355 5, an initial single pass is delivered across the forehead. The temples and crow's feet are treated at levels 352.5-353.0 in this first pass. lt is critical to reduce treatment fluences over the temporal region (lateral to the frontalis muscle) since there may be an increase in side effects (subcutaneous depressions or super- ficial burning) when settings over 353.0 are used in this thin tissue area. Extending treatment to the lateral periorbital region can have a significant impact on periorbital rhytides and can provide substantial local rejuvenation and tissue tightening that can affect adjacent areas (Fig. 4.5).
Pain sensation is a crescendo of warmth ending in a brief 'spike' of heat. Differing patient tolerances to this sensation may inhibit higher treatment levels. The sensa- tion appears to be stronger over the temporal area, where the frontaiis muscle is absent, and this is yet another reason the treatment setting should be dropped to 352.5- 353.0. Levels in all areas are adjusted to patient comfort
With the newer treatment tips, rapid cooling may allow for lower fluences to achieve a higher degree of dermal heating than with the standard original 1-cm2 slow tip.
The rapid cooling cycle may also give less protection to the epidermis than with the slow tip Therefore, lower fluences are needed to avoid overheating the epidermis and creating a superficial injury, burn, or blister. It is also essential not to overlap treatment areas, as the Z-second pulse with the fast tip allows the physician to move at a quicker pace. This can increase the chance of accidental 'double pulsing' at the edge of the treated area, and possible epidermal overheating and blistering.
Newer treatment recommendations utilize multiple passes (4 to 8) on the forehead over the brows. Multiple passes are performed only over the central two-thirds of the forehead where there is frontalis muscle deep to the treatment tip. Placement of subsequent passes is critical over 'lifting points,' from the medial to lateral portion of the brow extending up to the hairline. \A4ren this is per- formed, the entire first pass should be completed before returning to begin the second pass, thereby allowing time for residual dermal heat from the first pass to dissipate before retreating the same area.
It is important to know that patient tolerance is an indicator of treatment levels, and treatment levels should not exceed 355.5 on the forehead. Typically 75-150
Lasers and Lights Volume ll
Fig. 4'5 Periorbital rejuvenation following Thermage treatment Clinical example of patient prior to treatment (A), 2 months post-treatment (B) and 4 months post-treatment (C) (Photographs courtesy ot Thermage)
treatment pulses are required to cover the entire forehead and temples. This number may vary based on the size of the patient's forehead (men tend to have larger foreheads) and on the number of passes used
GALAXY
With the Galaxy system, the Polaris handpiece is applied for periorbital wrinkle reduction Employing the Polaris, an initial setting of radiofrequency of 50 J/cm2 to the forehead and 80 J/cm2 to the lateral and inferior peri- orbital regions and a diode setting of 20 J/cm2 should be used. The RF component should be increased by l0 J/cm2 per treatment to a maximum of 100 J/cm2 for the lateral and inferior periorbital region with subsequent treat- ments, whereas the fluence should be maintained at 50- 60J/cm2 to the forehead. The infrared (900 nm dtodeJ laser component should be increased by 2-4 J/cmz per treatment to a maximum of 36 J/cm2 in type I skin. The clinical endpoint of erythema should be achieved. The number of passes per treatment should be in the range of 6-10. A range of one to five treatment sessions at monthly intervals may be administered (Fig. +.6).
A C C E N T
For the Accent system, the unipolar handpiece is applied first at a starting fluence of l00J/cm2. One-to-three passes of 20-30 s each are applied to the entire periorbital region until a peak temperature of 40 " C is attained. Three successive maintenance passes in decrements of 10 J/cm2 should be applied. This is followed by the bipolar hand- piece with a starting fluence of 70 J/crnz administered in
a 20-30 second pass. Three successive passes in decre- ments of l0 J/cm2 per pass are administered (Fig. 4.7).
o Treatment of the lower face
T H E R M A C O O L
With ThermaCool, it is currently recommended to treat the entire cheek, jawline, and neck area as one cosmetic unit, beginning at the malar prominence and periorbital/
crow's feet area, extending medially toward the nasolabial folds, laterally toward the preauricular area, and inferiorly to the mandible. The jawline, upper one third of the neck, and submental region are included as well (Fig. +.8) One or two pulses on each side of the cutaneous upper lip may also be of benefit, but should be approached with caution and at very low fluences. It is recommended that treat- ment pulses be placed lateral and inferior to the bony orbital rim The initial pass of the lower face should be set at 353.0-355 5. However, results have improved sub- stantially when two, three, or as many as five passes are used (see Box 4.2) The skin is made taut, creating a trampoline-1ike effect, by putting tension on the skin to be treated with the nontreating hand. It is important for the treatment tip to meet some resistance when it is placed on the skin to allow equal contact throughout the surface of the electrode. It can also be useful to gently pull the skin off of the jawline and neck superiorly to move this skin offthe sensitive fand challengingly convex]
mandibular region.
Treatment settings for the first pass are usually in the 353 0-355.5 range for the entire lower face. A second and third pass at similar settings is performed in the same areas
67 Skin Tightening with Radiofrequency
Fig. 4.6 Periorbital rejuvenation following treatment with Galaxy. Clinical example of a patient prior to (A) and following (B) three treatments
Fig. 4.7 Periorbital rejuvenation followrng Accent treatment Clinical example of a patient prior to (A) and 3 months following (B) four treatments (Photographs courtesy Dr. Alexiades-Armenakas)
as the first. This can be followed by a fourth (approxi- mately 353.0-355.0), fifth, or even more passes in areas that require maximum contraction. There are differing theories as to the mechanism of action of the third throueh fifth passes, and they include:
* tissue tightening in the x [horizontal) and y (vertical) plane along the cutaneous surface
"t" compaction of fat and tissue tightening in the z-axis perpendicular to the skin, which pu1ls tissue in toward the bony underlying structures fvia tightening and contraction of fibrous septae in fat)
'i- a combination of the two.
This z-axis effect appears to be an important element of the improved results seen recently in treatment of the
58
L a s e r s a n d L i g h t s V o l u m e l l
Fig. 4.8 Lower face treatment with Thermage Patient prior to (A) and 6 months following (B) one pass at 1 5 0 J
lower face \A4rether this comes from additional tightening in the x (horizontal) and y (verticalJ plane or from a dlrect third-dimension effect on subdermal fat and collagen of the {rbrous septae remains to be determined
However, treating physicians can use these z-axis changes to their advantage. Multiple passes can therefore be carefully placed in areas rvhere maximal z-axis improve- ment is needed This would include the jowl and submen- tal region. Additionally, further x- and y-axis changes can be produced with these passes, and should include the preauricular region to create a 'vector'
of pull laterally.
The fourth, fifth, and more passes are used to augment the results of the third pass, and in many cases to achieve visible tissue tightening and contour changes at the time of the procedure
After treatment, the ink grid is gently wiped off with the aid of coupling gel or a gentle cleanser. Alcohol swabs should be avoided as thev mav cause irritation to the newly treated skin. The patieni is counseled to use sunblock containing a UVA block, such as zlnc oxide or titanium dioxide, for 7-10 days and to avoid direct sun exposure as UV rays can increase metallo- proteinases leading to potential collagen and elastic tissue degradation.
GALAXY
The Galaxy system's Polaris component provides the vast majority of skin tightening to this anatomic location. The Polaris handpiece is applied to the lower face and neck at an initial setting of at least 80 J/cm2 and a diode setting of 20 I/cm2 should be used. The thyroid region is to be avoided. The RF component should be increased by 10 J/
cm2 per treatment to a maximum of 100 J/cm2 The infra- red (900 nm diode) laser component should be increased by 2-4 J/cm2 per treatment to a maximum of 36 J/cm2 in type I skin. The clinical endpoint of erythema should be achieved. The number of passes per treatment should h e i n t h e r a n p e o f 6 - ] 0 . A r a n p e o f o n e t o f i r e r r e a r -' _ b ' " '
ment sessions at monthly intervals mav be administered
( F i g . + . s ) .
A C C E N T
The Accent system is applied to the lower face and upper neck, avoiding the thyroid area. The unipolar handpiece is applied first at a starting fluence of 100-l 10 J/cm2 in one to three passes of 20-30 s each. Once a peak skin surface temperature of 40-43'C is attained, three successive passes are administered in decrements of 10 J/cm2 each.
Fig. 4.9 Treatment of lower face with Galaxy. Patient prior to (A) and immediately following (B) a single treatment
This is followed by the bipolar handpiece with a starting fluence of 70J/cm2 in a 20-30 second pass, and three successive passes in decrements of l0J/cm2 each (Fig.
4.ro)
TROUBLESHOOTING
The ThermaCool device is equipped with sensors and mechanisms to detect if excessive or inadequate pressure is being applied during treatment pulses. The machine also aborts any treatment pulse if all four corners of the treat- ment tip are not in contact with the skin (when using the fast treatment tip). Sensors also alert the physician to excess temperature in the skin, as well as give information about the status of the cryogen module.
It is also essential to observe the impedance readings while treating different areas. Any site with an impedance less than 100 ohms should not receive further passes, as the risk for overheating and possible blister formation is increased.
The main concern with the Galaxy system is the bipolar nature of the handpiece. Good contact must be main- tained with adequate aqueous gel in order to prevent arcing. Arcing is the primary cause of crusting.
\A/hen using the Accent system, it is imperative that the physician maintain mobility of the handpiece through- out the procedure. The handpiece should not remain stationary on the skin in order to avert pain or thermal lnJury.
Skin Tightening with Radiofrequency
Fig. 4.10 Treatment of neck with the Accent Patient prior to (A) and immediately following a singe treatment (B) (Photograph courtesy of Dr Alexiades-Armenakas)