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Catinis et al. Plast Aesthet Res 2020;7:9 I http://dx.doi.org/10.20517/2347-9264.2019.68 Page 5 of 7

Figure 4. This patient is 83 years old in the left photo and 88 years old in the right photo. She was treated with the protocol described in
the Method Section and then continued with single quarterly treatments. During this five-year interval, she only received a total of 1.5 cc
of hyaluronic acid filler. The only other treatment she received during that time is neuromodulators

Combined focused monopolar RF and US in a single applicator improves noninvasive treatment of skin
[5]
laxity and fat reduction . The mechanical energy of ultrasound increases blood flow in the target tissue,
which causes higher conductivity of the tissue and leads in homogenous heating of the area. The other
effect is to increase cell permeability - the mechanical energy or mechanical emission to the cells increases
their responsivity to the treatment and the metabolic rate in the target area enables a faster and better
response. The combined effect allows more rapid, uniform heating of the skin.

After reviewing the literature, we developed a modified treatment protocol using combined RF and
US that has shown significant improvement in the maintenance and enhancement of both surgical and
nonsurgical rejuvenation of the face and neck. We enhanced the double injury protocol first suggested
[12]
by McDaniel et al. . The advantage of a slightly longer protocol (10 min vs. 6 min) to uniformly heat
the collagen to the ideal therapeutic temperature of 41-42 °C has proven to be comfortable and safe for
the patient. By pausing for approximately 10 min before treating a second time for 6 min during the same
visit, the chance of overheating and permanently denaturing collagen is reduced. After this initial injury,
inflammatory cells including neutrophils and macrophages remove cellular debris before the second phase
of repair begins. The tissue proliferation phase utilizes growth factors to increase fibroblast activity and
subsequent collagen production. This second phase typically peaks at Day 6 or 7 with inflammatory cell
response decreasing by Days 11-14. By repeating the RF/US protocol at two weeks, we suspect a sustained
inflammatory response leads to greater tissue remodeling. In our practice, we performed a pilot split face
study where one side of the face was treated with four sessions while the other side was treated according
to the Method Section above. No visible difference was noted in 2D photography. When compared to other
radiofrequency devices with protocols recommending three to five treatments, patients are pleased that
fewer treatments are needed to obtain similar clinical results. In clinical practice, we routinely re-assess
patients at three months after the second treatment and determine if he or she would benefit from another
combined RF/US treatment or if other modalities can be utilized to enhance outcomes. We have found that
our need for injectable fillers and collagen-stimulators has decreased in those patients who are receiving
maintenance treatments 2-4 times per year. One such patient is the 88-year-old woman in Figure 4.

There are several limitations to this unfunded pilot study. Only thirty subjects were treated, and no FDA-
approved photometric scale was utilized. Biopsies were not performed to histologically quantify collagen