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in the presence of factors that could alter or
impair wound healing, such as smoking [39].
Side effects: This technique usually has no
adverse effects due in large part to the mechanism of action of the pulsed focus ultrasound system [35].
23.2.4 Red Light-Emitting Diodes
Therapy
Recently, there has been an increasing interest
in attempting to treat obesity using non-invasive near-infrared radiation. Photobiomodulation
with red light-emitting diodes therapy is one of
the newest technologies for non-surgical fat
reduction, which uses red light therapy to
reduce the volume of subcutaneous fat cells.
This technology uses 650-nm red light-emitting
diodes. Near-infrared radiation is light existing
between visible-spectrum rays and mid-infrared rays, longer than a visible ray and shorter
than a mid-infrared ray, with a wavelength of
0.72–1.6μA [40].
Scientic basis: Instead of removing or
destroying fat cells, photonic lipolysis, or “red
light therapy,” delivers specic wavelengths of
light through the skin using a specialized lamp.
This light triggers the selected fat cells to create
small openings and release some of their contents, thus helping them shrink in size. The 600–
900 nm range light energy can pass through
human tissues much easier than other wavelengths. Once absorbed into the skin, it is transformed into cellular energy that stimulates a
variety of metabolic events [41] such as increase
in energy levels by the release of ATP, increase of
blood ow/circulation, bringing more oxygen
and nutrients to cells and tissues, and increase in
the production of collagen and broblasts, as
well as phagocytosis, or cellular clean-up; formation of new capillaries; activation of the lymphatic system; stimulation or decrease of
inammation and stimulation of DNA or RNA
synthesis; repair and restoring of damaged soft
connective tissue; and lowering effects of oxidative stress/free radical damage associated with
aging [42].
Application: It is intended to treat the abdomen, hips, or thighs. Treatments take about
30 min to perform, and patients usually need
three or more sessions to achieve their goals.
Expected results: Results begin to appear
within a few hours after treatment and continue
to improve as the body metabolizes the fat, which
is naturally eliminated as waste.
Post-treatment care: No special posttreatment care is required, and no downtime is
needed.
Contraindications for treatment: Patients
who are pregnant or have reduced liver function
should not undergo treatment.
Side effects:
risk treatment with no determined side effects.
Red light therapy is a very low-
23.2.5 High Intensity Focused
Electromagnetic Field (HIFEM)
High intensity focused electromagnetic eld is a
technology developed for non-invasive, nonionizing, non-radiating, and non-thermal procedures to simultaneously build muscle and burn
fat (Fig.23.3). Muscles represent approximately
35% of the human body’s weight, but existing
aesthetic treatments only address fat. The HIFEM
technology penetrates through the skin to impact
muscle tissues and abdominal fat, being the only
technology that simultaneously develops muscle
and burns fat, all without affecting the surrounding tissues [43].
Scientic basis: The energy produced by
HIFEM penetrates through the skin to impact
muscle tissues and abdominal fat. Focused energy
induces 20,000 muscle contractions per session.
During normal voluntary muscle contractions,
muscle bers relax between each nerve stimulus
due to the inability of the central nervous system
to receive another impulse while the former is
still in action. Through this technology, impulses
are generated, which are independent of brain
function and at such a rapid rate that it does not
allow for relaxation. Under normal conditions,
the greatest amount of tension that could be
developed and maintained physiologically is
called maximum voluntary contraction (MVC).
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Fig. 23.3 Example of HIFEM device
It usually lasts only for a fraction of a second.
Contractions with a tension greater than MVC
are dened as supramaximal. HIFEM can generate supramaximal contractions and maintain
them for several seconds, which signicantly
increases the physiological stress/workload necessary to allow the muscles to adapt. HIFEM
energy interacts selectively with motor neurons
while the skin is unaffected. Induced supramaximal muscle contractions are accompanied by a
rapid metabolic reaction in fat cells, generating
intensive lipolysis [44]. This metabolic reaction
overwhelms fat cells, which become dysfunctional and begin their programmed death (apop-
381
tosis). The resulting effect is a combination of
muscle strengthening, muscle growth, and fat
alteration. The lack of weight loss after treatment
thus appears to be a logical effect since the weight
of lost fat tissue is compensated by the weight of
gained muscle volume [45].
Application: It is intended for men, women,
young, middle-aged or even older people who are
not satised with the shape/condition of their
body. See Video 23.2. The use of the device is not
limited to (treating) patients who cannot achieve
the desired result of muscle denition in the gym
(Fig.23.3), but it also shows potential for candidates who are not suitable for other body modeling procedures, for example, heating or freezing
technologies. It is cleared to reduce fat and stimulate muscles in multiple body areas, such as
abdomen, buttock, arms (biceps and triceps) and
calves, and there are special protocols designed
for treating each of these body parts. During the
procedure, the patient can lie down and relax. A
course of treatment generally consists of four
30-min sessions spaced 2 or 3 days apart. The
procedure does not require any recovery time.
Usually, patients can return to their daily routine
immediately after each session.
Expected results: Positive results are usually observed 2–4weeks after the last session
and continue to improve for several weeks after
treatment. According to clinical studies, mean
increase in muscle mass is 16% and mean fat
reduction is 19% [46, 47]. The effects have
been tested in various clinical studies, in which
very well-established evaluation methods
(MRI, CT, ultrasound, and histology) were used
during the tests, and results consisting of muscle gain and fat loss were obtained. One study
on women at 3 to 36 months after delivery
showed a mean decrease of 17.7% in abdominal
fat thickness. Muscle thickness increased a
mean of 17.85%, and abdominal separation
decreased a mean of 16.6%. The improvement
measured in this group of postpartum women
was 60% higher than that observed in the normal population. The study concluded that the
HIFEM procedure is highly effective and safe
for the change of image in postpartum women,
especially thanks to its effect on abdominal
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separation. Compared to other non-invasive
body-shaping technologies, HIFEM showed
competitive results regarding waist circumference reduction. A study on cryolipolysis
reported a circumference reduction of 6.86cm,
[48] an LLLT study reported waist reduction of
6.83cm, [49] and an RF study showed 4.93cm
[50]. Studies on HIFU showed a reduction of
4.1–4.7 cm [38, 51]. Based on the results
obtained in a study with HIFEM, where mean
waist reduction was 4.37cm, it seems this technology is highly competitive.
Post-treatment care:
No special posttreatment care is required, and no downtime is
needed.
Table 23.1 Summary table for abdominal fat reduction techniques
Technique Indications Advantages Disadvantages Side effects
Cryolipolysis Subcutaneous fat
Low-level laser
therapy
Red lightemitting diodes
High intensity
focused
electromagnetic
eld
In my experience, the best results for abdominal fat reduction are obtained with cryolipolysis and HIFEM.Both
techniques combined promote better outcomes
reduction
Abdomen and anks
fat reduction
Abdomen, hips, or
thighs fat reduction
Reduce fat and
stimulate muscles in
multiple body areas,
such as abdomen,
buttock, arms (biceps
and triceps), and
calves
Reduce subcutaneous
fat while leaving the
surrounding structures
intact
Minimal recovery
time
results can be
maintained in the
long term
Is painless and
patients only feel a
warming sensation
Results are noticeable
after about 6weeks
Patients resume
normal activities
immediately after
treatment
Results begin to
appear within a few
hours after treatment
Positive results are
usually observed
2–4weeks after the
last session and
continue to improve
for several weeks
after treatment
Contraindications for treatment: This technology uses a strong magnetic eld, so it is contraindicated in patients who have metallic and
electronic implants (e.g., cardiac pacemakers).
Its application is also contraindicated in the area
of the head and heart or in patients with specic
medical contraindications such as malignant
tumor, injured or damaged muscles, fever, and
pregnancy.
Side effects: Muscle fatigue is a relatively frequent side effect that resolves within 12–48h,
[45] and mild muscle soreness resolved one day
after the rst session within 24h [46].
In Table23.1, a summary of all the abdominal
fat reduction technique can be found.
Is not a method for
weight loss
Not appropriate for
patients with coldsensitive conditions
Results are noticeable
after about 90days
Precautions must be
taken when the patient
has keloids, implants,
permanent dermal llers,
and in the presence of
factors that could alter or
impair wound healing,
such as smoking
Patients who are pregnant
or have reduced liver
function should not
undergo treatment
It is not allowed for
patients who have
metallic and electronic
implants, malignant
tumor, injured or
damaged muscles, fever,
or pregnancy
Temporary
erythema, mild
swelling,
tingling,
bruising,
transient
numbness
Discomfort
during
treatment,
burns,
temporary
nodules,
prolonged
tenderness
It is a very
low-risk
treatment with
no determined
side effects
Muscle fatigue,
mild muscle
soreness
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23.3 Stretch Mark Reduction
Stretch marks (also known as striae gravidarum)
are common adverse skin reactions caused during pregnancy that affect approximately 50%–
90% of pregnant women. In pregnant women,
younger age, maternal and family history of
stretch marks increased pre-pregnancy and predelivery weight, and increased birth weight were
the most signicant risk factors identied for
striae gravidarum [52]. In pregnant women, itchy
stretch marks can be a sign of gestational herpes
[53]. Stretch marks are also seen in other conditions, such as rapid weight gain (obesity), muscle
hypertrophy (bodybuilders), endocrinopathies
(such as Cushing’s syndrome), breast augmentation, as a side effect of topical use and abuse of
corticosteroids and as a complication of tissue
expanders. In women, they are more frequent in
the thighs, abdomen, and chest, and in men, in
the upper arms [54–58]. Therapies targeting
stretch marks should induce a controlled inammation in the dermis that results in the stimulation of neocollagenesis through the recruitment
of broblasts; these are listed in Table23.2 and
some of them are detailed above. To be effective,
in addition to neocollagenesis, these modalities
should also reduce erythema and improve pigmentation in the case of striae alba [59].
23.3.1 Laser Treatment
Several treatments have been proposed to aesthetically improve striae. The natural course of
stretch marks argues for an increased vascularity
in the early lesions (striae rubra). Hence, here,
vascular lasers should have a benecial effect,
since hemoglobin works as a chromophore for
specic lasers acting in this vascularity. Various
types of lasers have been tested in the treatment
of stretch marks with diverse results (see
Table23.1). The 585nm pulsed dye laser with a
10 mm spot size using 3.0 J/cm2 uence can
improve the appearance of striae and a histologic
evaluation argued for the restoration of the elastin
ber network, as a small study found [60]. Other
Table 23.2 List of technologies for non-invasive procedural therapies to treat stretch marks
Lasers
Ablative fractional CO2 laser (10,600nm)
Non-ablative fractional Er:YAG laser (1540nm)
Non-ablative diode laser (1450nm)
Nd:YAG laser (1064nm)
Flashlamp-pumped pulsed dye laser (585nm)
Copper bromide laser
Excimer laser (308nm)
Radiofrequency (RF) (ablative/non-ablative)
Non-fractional
Fractional
Microneedle radiofrequency (MNRF)
Microneedling therapy or percutaneous collagen
induction therapy
Light-based therapies
Intense pulsed light
UVB/UVA1 combined therapy and targeted
phototherapy
Infrared light
Galvanopuncture
Carboxytherapy
Microdermabrasion
Platelet-rich plasma (PRP)
Chemical peeling
studies using the ashlamp-pumped pulsed dye
laser (585nm) showed some benecial effects,
such as striae width decrease, skin texture
improvement, and increase of collagen expression with the exception of collagen I [61].
Scientic basis: Light energy emitted by laser
devices on the skin is coherent, cohesive, and
monochromatic light energy that acts on a specic tissue chromophore. Lasers target different
chromophores such as water, hemoglobin, and
melanin, and therefore improve the overall
appearance of the stria by increasing collagen
production, decreasing vascularization (especially in striae rubra) and increasing melanin pigmentation [62, 63].
Application:
1. Pulsed Dye Laser: It has shown that it is
effective only for the immature element of
stretch marks (striae rubra), being directed at
the vascular element; it is not effective on dark
skin and is associated with pregnancy- induced
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hypertension; when combined with radiofrequency, it has a better response even in stretch
marks [60, 64, 65]
2. Copper Bromide Laser: In one study, a
577 nm laser showed a mild-to-moderate
effect on skin types II and III [66]
3. 1450-nm Diode Laser: Not useful on skin of
color (IV–VI) and associated with many complications [67]
4. 1064-Neodymium-Doped Yttrium Alumi-
num Garnet Laser: Targets are immature
striae with satisfactory results achieved so far
[68–70]
5. Excimer Laser: It only repigments temporar-
ily and does not have an effect of atrophy [71]
6. Fractional Photothermolysis: It has shown
efcacy in the treatment of mature and immature stretch marks and an increase in the number of collagen and elastin bers, with a good
safety prole [72–74]
Expected results: Although a variety of lasers
have been used in striae distensae (SD), results
are inconsistent, and there is a lot of variety. The
best results obtain an improvement of 80%, [75]
and a satisfaction of 71.4% [76]. Ablative and
non-ablative fractional lasers may have shown
the maximum benecial result [59]. Lasers in
combination with other modalities, such as topical agents and additional energy devices, like
radiofrequency, have also demonstrated promising preliminary results [62]. Usually, three to ve
sessions are required before effects are noticeable, and results appear within 2–6months after
the nal session.
Post-treatment care: Keep the skin moisturized, and no special post-treatment care is
required. No downtime is needed.
Contraindications for treatment: On ethnic
skin (skin types IV-VI), treatment with ashlamppumped pulsed dye laser (585 nm) should be
avoided due to the risk of permanent pigmentary
changes [77].
Side effects: The treatment is usually well tolerated. There were no signicant long-lasting
adverse effects, except transient mild erythema
and pigmentation.
23.3.2 Radiofrequency (RF)
RF technology is different from cosmetic lasers,
since it produces an electric current instead of
light. The energy produced is not likely to
decrease due to tissue diffraction or epidermal
melanin absorption, thus being appropriate for
any type of skin [78]. RF original devices were
monopolar or bipolar, and the newer that are
available today can be multipolar, fractional,
pulsed, and phase-controlled [79]. This technology supplies uniform heat at controlled depth to
the dermal layers, causing direct collagen contraction and immediate hardening of the skin,
leading to the remodeling and reorientation of
collagen bundles and the formation of new collagen for months after treatment. This technology
has been used in conjunction with other modalities like pulsed dye laser [80], autologous platelet-rich plasma [81], pulsed magnetic elds [82],
and infrared light therapy [83], as well as topical
options, like retinoic acid [84], and found it to be
more efcacious than RF alone in management
of SD.
Scientic basis: The supposed mechanisms
of fat reduction after RF are thermal stimulation
of adipocyte metabolism through enzymatic degradation mediated by triglyceride lipase and
apoptosis and adipocyte rupture. Radiofrequency
energy is conducted electrically to the tissue,
generating heat when the inherent resistance
(impedance) of the tissue converts the electric
current into thermal energy. This generated heat
results in tightening of the skin within the dermal
tissue through immediate denaturation and contraction of collagen bers and later forms new
collagen in subsequent weeks and months [85].
Fractional RF treatment is characterized by the
delivery of very short and high-intensity electric
shocks at an adjustable repetition frequency.
Fractional RF uses a handheld device with a
series of microneedles, which can vary in number
from 5 to 225, and produce a series of “microdamaged” heat points in/on the skin that initiate
the regenerative process.
Application: Radiofrequency has become
popular for its effectiveness to treat acne scars,
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keloids, rosacea, and inammatory acne, as well
as to improve skin laxity and reduce rhytides
[86]. Radiofrequency can be used on areas of the
body other than the abdomen, including the neck,
face, arms, thighs, knees, and buttocks. It generates lower temperatures than lasers and can be
focused specically on the dermis [87]. The
treatment protocol requires one or more passes
over the area to be treated, depending on the
complexity of the case, and each therapy session
can last from 15 to 35/45 min. The treatment
requires the application of a simple gel or a gel
with hyaluronic acid or other active ingredients,
to enhance the anti-aging effect.
Expected results: Studies on the effects of the
use of RF devices in combination with laser still
suggest that it is a synergistic, effective, and safe
modality that could be a good alternative for
stretch marks. A study combining both technologies in Asian patients with a darker skin tone, and
in which a session with RF and pulsed dye laser
was performed, plus two additional sessions with
pulsed dye laser, 89% of the patients had a general improvement from “good” to “very good,”
and 59% had elasticity results improved from
“good” to “very good.” All histological evaluations showed an increase in the amount of collagen bers, and six of the nine samples had an
increase in the number of elastic bers.
Hyperpigmentation is considered only in one
study patient, which improved in 3months [80].
Post-treatment care:
treatment care is required, and no downtime is
needed. After the procedure, patients should not
be exposed to the sun in the following 2weeks
and must apply a lter or protective cream on the
treated area for at least 1month whenever outdoors [88].
Contraindications for treatment: Patients
with implantable medical devices, such as pacemakers or debrillators, collagen vascular diseases, or autoimmune diseases. Caution is required
with patients who are under radioactive treatment
or have recurring herpes infections [89, 90].
Side effects: The side effects of RF treatment
are rare but when they occur, they tend to be reddening of the skin, erythema, edema, or swelling
No special post-
that usually lasts for up to 24h [91], and micro
burns [88]. As in the case of non-fractional RF,
fractional RF can also have side effects, which
are characterized by burning points that heal
within 5–7days [88].
23.3.3 Microneedling (Collagen
Induction Therapy)
Microneedling, also known as skin puncture or
percutaneous collagen induction therapy, is a
technology that involves the use of ne needles
(1–1.5mm) to create microdermal wounds [79].
This is considered a safe therapy for skin rejuvenation because it produces minimal damage to
the skin and much less epidermal damage than,
for example, laser ablation. There is also a lower
risk of hyperpigmentation and with microneedles, making it an appropriate treatment option
for people with thin, sensitive, or ethnic skin
types (>III) [79].
Scientic Basis: These controlled microskin
injuries with minimal epidermal damage stimulate a cascade of dermal wound healing (inammation, proliferation and remodeling), which
leads to the release of the platelet-derived growth
factor, broblast growth factor (FGF), and transforming growth factor alpha and beta (TGF-α
and TGF-β) [92, 93]. Subsequently, a bronectin
network is created, providing a matrix for the
deposition of type III collagen, which is eventually replaced by type I collagen, resulting in
decrease in appearance of ne lines and wrinkles,
skin laxity, and scarring [94]. One day after needling therapy, keratinocytes begin to proliferate
and release growth factors to promote collagen
deposition by broblasts. Needling therapy modulates the expression of several genes in the skin
(vascular endothelial growth factor, broblast
growth factor, epidermal growth factor, type I
and III collagen) that promote extracellular
matrix remodeling [93, 95]. A study with individual human skin biopsies [96] only revealed
changes in growth factor expression associated
with the de novo synthesis of collagen (e.g.,
TGFβ1–3, FGF, EGF, VEGF, TNF-α).
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Application: Microneedling is a relatively
new treatment option in dermatology with
many applications, including skin rejuvenation,
acne scarring, rhytides, surgical scars, dyschromia, melasma, enlarged pores, and transdermal
drug delivery [97]. (See Fig. 23.4 and Video
23.3) No single optimal treatment has been
indicated for SD, so needling therapy may be
considered a reasonable therapeutic option for
the treatment of striae lesions [98]. A major
advantage of microneedling is that it is less
invasive and can be applied under local anesthesia (reinforced EMLA cream, emulsion in
which the oil phase is a eutectic mixture of
7.0% lidocaine and 7.0% prilocaine, containing
tetracaine 6.0% as well). In microneedling therapy, the epidermis remains relatively intact,
Fig. 23.4 Example of microneedling device
which helps to limit post- procedural adverse
events, such as bleeding, swelling, and pain
[99]. It requires wearing a compression garment for 4–5days following the procedure, and
skin care is necessary.
Expected results: In a study on women with
striae distensae, 43.8% of stretch mark distensions showed a clear improvement 3months after
the nal session, and >85% of patients were
somewhat or very satised with the results of
their treatment (See Fig.23.5) [98].
Post-treatment care: In the morning and at
nights after treatment, a soothing and moisturizing compound should be applied, and also wear a
compression garment for 4–5days following the
procedure.
Contraindications for treatment: Patients
with dermatosis like vitiligo, lichen planus, and
psoriasis as a consequence of trauma leading to
koebnerization (or Koebner’s Phenomenon),
which can aggravate the dermatosis; patients
with blood clotting disorders and on any anticoagulant therapy, like warfarin or heparin, as it can
cause uncontrolled bleeding; patients with rosacea; skin malignancy, moles, warts, and solar
keratosis (as needles may disseminate abnormal
cells by implantation); patients with chronic skin
diseases like eczema; history of taking isotretinoin in the last 6months; extreme keloidal tendency; on chemo or radiotherapy; and if the area
is infected [100].
Fig. 23.5 Before and after of microneedling treatment
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Table 23.3
Technique Indications Advantages Disadvantages Side effects
Laser Treatment of mature
Radiofrequency Acne scars, keloids,
Microneedling Skin rejuvenation Lower risk of
In my experience, the best results for stretch mark reduction are obtained with microneedling
Summary table for stretch mark reduction techniques
Striae width
or immature stretch
marks, depending on
the laser type
rosacea, and
inammatory acne,
as well as to
improve skin laxity
and reduce rhytides
on areas of the body
other than the
abdomen, including
the neck, face, arms,
thighs, knees, and
buttocks
decrease, skin texture
improvement, and
increase of collagen
expression (except
collagen I)
Appropriate for any
type of skin
Remodels and
reorients collagen
bundles and promotes
the formation of new
collagen for months
after treatment
hyperpigmentation
than laser
Modulates the
expression of several
genes in the skin that
promote extracellular
matrix remodeling
Appropriate for
people with thin,
sensitive or ethnic
skin types (>III)
Not good results on
skin of color (IV–VI)
Not allowed for
patients with
implantable medical
devices, collagen
vascular diseases or
autoimmune diseases.
Caution with patients
who are under
radioactive treatment
or have recurring
herpes infections
Not allowed for
patients with some
dermal diseases (see
contraindications for
treatment), or blood
clotting disorders and
on any anticoagulant
therapy
There were no
signicant longlasting adverse
effects, except
transient mild
erythema and
pigmentation
Are rare: reddening
of the skin, erythema,
edema or swelling
that usually lasts for
up to 24h
Pain, reactivation of
herpes simplex,
impetigo
Allergic contact
dermatitis to the
material used in
needles
Tissue damage and
hemorrhage with
linear hypertrophic
scars or post
inammatory
hyperpigmentation
Side effects: Complications are almost negligible. Side effects include pain, reactivation of
herpes simplex, impetigo, allergic contact dermatitis to the material used in needles, more tissue damage and hemorrhage with linear
hypertrophic scars or post-inammatory hyperpigmentation due to the dermaroller being used
in many treatments. Also, there is a risk of exposure to blood [100].
To conclude, in Table23.3, a summary table
for stretch mark reduction techniques can be
found.
23.4 Lax Skin Tightening
23.4.1 Radiofrequency (RF)
Radiofrequency generates heat in different tissues by transforming energy through three basic
mechanisms from electromagnetic eld. When
collagen is heated to 65–75°C, there is immediate denaturation of the triple helix, followed by
recoil and contraction of collagen bers [4]. The
nal goal of this technology is to induce thermal
damage to stimulate changes in collagen confor-
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mation and produce neocollagenesis in deep layers of the skin and subcutaneous tissue [101].
Scientic basis: Studies have observed that
the amount of synthesized collagen depends on
the heating intensity of the connective tissue
[102] and the rising of temperature and the depth
of heating depends on the level of energy used
and on the impedance of biological tissues [103].
The thermal effects of RF can change the shape,
length, and diameter of collagen bers for the
reorganization of collagen [102]. Collagen is a
protein composed of three polypeptide chains
that form a triple helix structure. The process of
thermal contraction of collagen begins with denaturation of the triple helix, which means that collagen undergoes a transition from a highly
organized crystalline structure to a gel-like state.
Collagen contraction occurs by the cumulative
effect of the unwinding of the triple helix due to
the destruction of intermolecular cross-links and
the residual stress of such links. About 8weeks
after collagen denaturation, there is an induction
of new collagen synthesis (neocollagenesis) [85].
Radiofrequency energy is free from the inuence
of diffraction, absorption by chromophores, or
other tissue interactions, which, therefore, have
no inuence on the epidermal melanin. For this
reason, it can be used on any skin types, and it is
possible to control the depth of the energy’s inltration [104].
Application: There is no standard procedure
to reference the parameters used with RF, such as
frequency and device power, treatment time and
temperature maintained in the skin; thus, it is
necessary to use appropriate parameters for the
achievement of therapeutic results, since the
effects induced by electromagnetic elds are
dependent parameters [105, 106]. The outcomes
so far have shown that the RF treatment is effective and safe for treating aging skin and scars in
mild-to-moderate degrees of severity, and
patients go back to their normal lives after the
procedure [107].
Expected results: Signicant statistical outcomes about the effects of RF on skin laxity are
low and limited. In animal studies, the most sig-
nicant changes were found 2months after the
last application. In the biopsies taken at this time,
an increase in the amount of collagen, elastic
bers, and mucopolysaccharides was noted
[108]. The treatment of laxity sometimes requires
more invasive or combined treatments to achieve
better results, such as laser, botulinum toxin, or
llers, etc., allowing to reach maximum effects
with minimum downtime [107].
Post-treatment care: No special posttreatment care is required, and no downtime is
needed.
Contraindications for treatment: Patients
with implantable medical devices, such as pacemakers or debrillators. It is also contraindicated
in collagen vascular diseases or autoimmune diseases. Caution is required with patients who are
under radioactive treatment or have recurring
herpes infections [89, 90].
Side effects: This technology causes few side
effects and little to no downtime. Almost all studies have reported no permanent side effects following treatment [91]. Some common side effects
are pain (generally low), reddening of the skin
after a procedure, erythema that typically disappears within 24 h after treatment, or edema or
swelling that can be expected to last for up to
24h after treatment, although some patients may
experience edema for up to one week.
23.4.2 Ultrasound Skin Tightening
Microfocalized ultrasound has been developed to
achieve a signicant stretching of the skin using a
non-invasive method [109].
Scientic basis: Microfocalized ultrasound is
focused on the subcutaneous tissue, at a depth of
up to 5mm in the middle-to-deep reticular layer
of the dermis and subdermis. In contrast with
high-intensity focused ultrasound, microfocused
ultrasound uses much lower ultrasound energy to
treat the supercial layers of the skin, i.e. 0.4–
1.2J/mm2 of energy, a frequency of 4–10MHz,
and a focal depth of only 1.5–4.5mm, [110] in
spite of which it reaches a temperature over 60°C
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for a short time, producing small points (<1mm3)
of thermal coagulation. At these points, collagen
bers in the facial planes, such as the supercial
musculoaponeurotic system and the platysma, as
well as the deep reticular dermis, are denatured,
contract, and stimulate de novo collagen. This
occurs by breaking the intramolecular hydrogen
bonds that cause collagen chains to fold and
assume a more stable conguration, resulting in
shorter and thicker collagen. In addition, de novo
collagen formation and new forms of viscoelastic
collagen occur within the areas of thermal tissue
coagulation, resulting in the stretching of lax
skin. Intermediate papillary dermal and epidermal layers are not affected [109].
Application: There is no standard protocol
for abdominal treatment. Studies report procedures with different number of passes, time of
exposure and energy, and results are disparate as
well [37].
Expected results: Results are seen within
2–6 months, but multiple sessions may be
required before effects are noticeable. One study
reported a mean waist circumference reduction
of 4.4 cm after an application (two passes) of
high-intensity focused ultrasound to the abdomen
and anks with a mean energy dose of 137J/cm
2
[111].
Post-treatment care: No special posttreatment care is required, and no downtime is
needed.
Contraindications for Treatment: Infections
and open skin lesions, and the presence of active
metallic implants, such as pacemakers or debrillators, in the target area. For facial treatments, it
is contraindicated when there is active severe or
cystic acne. Precautions include treatment
directly over keloids, implants, permanent dermal llers, and the presence of factors that could
alter or impair wound healing, such as smoking
[39].
Side effects: Brief discomfort during treatment can be minimized with oral non- steroidal
anti-inammatory drugs. Other treatment-related
adverse events include transient erythema,
edema, and occasional bruising.
23.5 Intense Pulsed Light
withRadiofrequency (RF)
This is a combined treatment to heat deeper layers of skin and induce a natural healing response,
which in turn triggers collagen production. The
addition of intense pulse light allows treating the
skin at multiple levels and can help focus the RF
energy more effectively. The goal of combined
RF and light sources is to safely and effectively
target tissue that will selectively absorb energy to
produce thermal changes without injury to surrounding tissues and stimulate collagen generation [112].
Scientic basis: This technology combines
light and radiofrequency into a single energy
source. Although each has different selectivity
mechanisms, both techniques work synergistically to generate localized heat in a target tissue.
The main advantages of this combined technology are a reduction in optical or laser energy,
which provides greater security and makes it suitable for all skin types, and a potential compensation for this reduction with electrically conducted
RF energy [112]. At the same, the effectiveness
of the treatment is not compromised because the
energy of the RF that is simultaneously conducted coagulates the target without damaging
the surrounding tissue [113].
Application: Treatments can be performed
in-ofce with little to no downtime. Clinical
applications of the combined technology include
the removal of hair and leg veins, skin tightening,
skin rejuvenation, and wrinkle reduction.
Expected results: Results appear gradually as
the skin produces new collagen. Most patients
begin with three to ve sessions, spaced
3–4weeks apart.
Post-treatment care: Keep the skin moisturized and with sun protection and no special posttreatment care is required. No downtime is
needed.
Contraindications for treatment: It may not
be suitable for darker or tanned skin.
Side effects: Adverse side effects are minimal
and include transient, mild erythema, mild swell-
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