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Nonsurgical tightening with devices has been reported with unipolar radio frequency, bipolar radio frequency, and combined unipolar and bipolar radio-frequency devices, combined radio-frequency devices and laser, broadband infrared light sources, long-pulsed infrared lasers, and fractional laser resurfacing. The common feature for all these devices is that they are “color-blind” in theory, and should not pose significant risks for darker skin, as they do not interfere with the chromophore melanin. Specific studies addressing dark skin patients with these devices is limited and it is generally assumed that because of the lack of competing chromophores, skin tightening with all the aforementioned devices should be safe in skin of color. The bigger controversy is the actual efficacy of these devices in actual three-dimensional skin tightening, regardless of the color of the skin. This chapter will review the various devices utilized for skin tightening, their mechanisms of actions, issues regarding skin of color, and potential complications.


Monopolar capacitive radio frequency is the most widely studied device for nonsurgical skin tightening and was the first modality launched specifically for this indication.1–3 The mechanism of action involves selective heating of the dermis and subcutaneous tissue with monopolar capacitive radio frequency, while protecting the skin surface, thereby preserving epidermal integrity. The initial approach to monopolar radio frequency was to utilize high fluencies with single treatment or two treatments.3–5 The literature shows small studies on patients up to skin type IV using this protocol,4 without reported risks of any complications such as hypopigmentation or hyperpigmentation or scar formation with longevity of approximately 6 months. The high fluence protocols lost momentum for various reasons including significant discomfort, unpredictability and the potential for subcutaneous atrophy, as well as epidermal compromise5 (Figure 12.1). Moreover, the duration of treatment was exceedingly slow, making it cumbersome and painful. To overcome these limitations, the high fluence protocol was replaced with a low-energy multiple-pass technique6 with 5700 patient assessments in a 14-Physician Multispecialty Consensus Panel. This is the largest series of any tissue tightening device to this date. Parameters assessed with the newer protocol, included1 patient feedback on heat sensation as a method for optimal energy selection2, the use of multiple passes at moderate energy settings to yield more reproducible and consistent outcomes, and3 treatment to a clinical endpoint of visible tissue tightening for more predictable results. In comparison to the original algorithm of high fluence, single pass treatment, which showed skin tightening in 54% of the patients and significant pain in 45% of patients, the new algorithm of multiple passes with lower fluencies, showed tightening in 92% of patients and significant pain in 5% of patients. Therefore, it appears that multiple pass lower fluence monopolar capacitive radio frequency is now the preferred modality for noninvasive skin tightening, with the largest series of treatments and most widely peer reviewed studies. Specific ethnic skin studies ...

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