The use of radiofrequency is progressing with combined treatments for better, safer results. Shared information between clinicians and manufacturers helps to improve protocols and the technology. Dr Aamer Khan explains what the future holds for radiofrequency
I first started working with radiofrequency in 2005, doing minor operative surgery. We found that the actual end results were much better this way. Healing was improved and the actual dissipation of energy and trauma into the skin was reduced. It was a very precise method.
One of the philosophies at our clinic is to be at the cutting edge—it is important to innovate. We have got to look at combining treatments, so we don’t push any one treatment to the point of risk.
We don’t just use radiofrequency for cosmetic medicine—there is a lot of evidence behind its use in other fields too. However, cosmetic and aesthetic medical surgery are relatively new and we want to gather more information to see where these two particular fields can progress.
Benefits of radiofrequency
A lot of the companies that are using radiofrequency are developing whitepapers and case studies. We’re starting to look at the specifics of what we should be targeting, the length of time that we should be targeting the energy and what the results are.
The three types of thermal effect that we get with all energy delivery systems are:
1. Ablation of tissue—used specifically for cutting and removing with high power density.
2. Coagulation of tissue—a sub-necrotic to necrotic border and that creates release of thermal induced proteins and cytokines which will then trigger healing.
3. Sub necrotic healing—for collagen contraction using low power density.
The good thing about radiofrequency is that you get all three of these happening at the same time. The gentle heating has also been shown to increase the healing of tissues, in fact in physiotherapy it’s used to heal injury.
The technical advantages are high efficiency and reliability of radiofrequency sources. Because it’s an electrical ‘solid state’ type of technology there is consistency in the delivery. We can choose how much power we apply, and with stretch marks, the higher the power the better. But delivery of power isn’t everything—safety and reduction of side effects is why we’re combining treatments.
In our clinic we use radiofrequency for cosmetic radio surgery, which gives us ‘microscopic’ scar healing where we can almost ‘airbrush’ lesions away. We use it for cutting surgery as well because we find that the tissue healing is much better.
We also use it for radiofrequency assisted liposuction where different tissues are targeted with radiofrequency. As well as fat apoptosis, the interstitial fibrous bands can be contracted significantly. We use it for tissue contraction, tissue de-bulking and skin tightening.
Tissue de-bulking relates to post-obesity problems. One of the problems with putting on weight is that there is expansion of the tissues around the fat, and there is actually a hypertrophy of the interstitial fibrous bands, and the inter-adepose cellular tissue, which prevents efficient contraction of the tissues when people lose weight. So they can have skin that weighs far more than normal skin and is much thicker.
Radiofrequency can be used to de-bulk this, and we are working on protocols with surgeons where tissue is being removed, but we’re also de-bulking tissues to make it thinner and tighter.
The fibrosis and microfibrosis that occurs prevents tissue weakness, so we’re also working with invasive, interstitial, heating and radiofrequency. This causes microscopic interstitial fibrosis in a diffuse fashion, strengthening and contracting the tissues.
We also use radiofrequency for significant scars by using deeply penetrating probes, including 3mm probes for burn scars. We’re doing a lot of work with soldiers after they’ve been burnt and injured and we’re seeing really good results. In the future we will be able to use this in combination, certainly, with PRP and with other modalities.
In treatment of acne and the application of non-necrotic, sub-ablative thermal healing energy, we have seen that it reduces the acne process. Patients have come in with active acne, which has settled down quite significantly and quite quickly as a result of treatment with radiofrequency.
Looking to the future
So what does the future hold? The future has to be developed through teamwork. Through observation, study and clinical research by the people who are using the technologies in combination with technical developments by the companies.
Through talking and sharing information, and having peer reviews, so we can evolve better and safer protocols for our patients.
We’re always learning and moving forwards. That’s part of our role as clinicians—to have safer ways of achieving results and we’re coming back again and again to combining treatments. We’re also now using radiofrequency skin rejuvenation prior to cosmetic surgery.
A very interesting study looking at expectations in cosmetic surgery was done by Ohio University. One of the issues in our field is expectations and outcomes—we have got to match them. If we don’t match them as closely as possible and if we don’t manage the expectation, there can be a huge disappointment gap, and this is when patients complain.
Ohio University asked patients and doctors what the expected age reduction was after a facelift. People thought it was anything between five and ten years. They then did a study looking scientifically at what actually was achieved, and the average improvement was about three and a half years. Now when you combine surgical and non-surgical or minimally invasive treatments, then we can achieve a five to ten years.
So the future of radiofrequency, I believe, is in preparing for surgery. This means that our surgical colleagues have much better skin (material) to work with when they operate. Post surgically we can maintain that improvement with further treatments.
It’s not just about treating. With the stretch marks there are studies being done looking at epidermal thickness after ablative and sub-ablative radiofrequency treatment. That thickness will last about 12 to 18 months before it regresses back to age. Ongoing treatment with retinols will help, but remember the skin needs a rest as well. Ongoing treatment with non-ablative surface radiofrequency every three months can keep that topped up because we’re putting energy in without ablating.
Looking at protocols for long-term maintenance is something that we can do to move forward. It’s important to support our patients long term, putting together treatment programs for them, rather than just ending at surgery and coming back three to five years later to say this has not worked, or lasted
Understanding the required end points and developing technological advancements to monitor and achieve these endpoints is what we’re moving towards.
For example, when we started doing radiofrequency assisted liposuction we were putting energy in for tissue contraction. The temperatures were going up to 80 degrees and we were getting coagulated tissue which was actually preventing early contraction of tissues. We were seeing end results after two years rather than three to six months and patients were unhappy because of the gap between expectation and outcome.
With the newer protocols we now know we only have to go up to 60 degrees for significant interstitial fibrous contraction to occur, so we’re seeing those results a couple of months after they’ve had their treatment. This is now exceeding their expectations, and the patients are much happier, despite the two years outcome remaining unchanged.
This advancement only occurs when we feed back to each other and share information, not just between ourselves but also to the manufacturers. If the manufacturers can work with us in achieving technologies which can monitor the end results that we’re aiming for, then we can get better results.
So the future is quite exciting. We have a modality here which can do a number of things—anything from ablation all the way through to gentle warming and healing.
Dr Aamer Khan is a cosmetic doctor, and co-founder of the Harley Street Skin Clinic. W: harleystreetskinclinic.com