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Page 2 of 7 Catinis et al. Plast Aesthet Res 2020;7:9 I http://dx.doi.org/10.20517/2347-9264.2019.68

Figure 1. Treatment was started at the center part of the forehead and moved to the temporal region using slow, overlapping circular
motions

greatly increased in popularity due to their effectiveness in improving skin laxity, while also minimizing
[2,3]
recovery time, risk of adverse effects, and cost . Such noninvasive methods include radiofrequency (RF),
ultrasound (US), and a variety of other energy-based and mechanical devices.

The application of RF to the skin generates heat at the level of the dermis by generating an oscillating
current within the target tissue. The controlled heating of the dermis leads to the denaturation of the
helical structure of collagen and an inflammatory response with subsequent activation of fibroblasts. As
the collagen undergoes repair and remodeling, the dermal health improves with decreased skin laxity and
[4-7]
increased elasticity .
Ultrasound similarly induces dermal collagen synthesis and remodeling through the production of
heat. The emission of sound waves through the tissue causes molecules to oscillate, which results in the
[4,8]
production of thermal energy .

Although the use of RF and US as individual modalities for the treatment of skin laxity has proven to be
effective, the unique combination of the two in one handpiece allows shorter treatment times with more
consistent results in our practice. 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. In
addition, ultrasound increases cell permeability, allowing the radiofrequency to have even more effect on
fibroblast stimulation. The following details our modified treatment protocol that has improved patient
outcomes.

METHODS
After applying a ground pad opposite to the upper right back, the facial skin was cleaned with one pass
with alcohol-soaked gauze and then one pass with acetone-soaked gauze. Ultrasonic gel was applied and a
combined radiofrequency and ultrasound applicator (small handpiece of the Exilis Ultra by BTL Industries
Inc., Boston, MA) was used to heat the facial skin to a therapeutic temperature of 41-43 °C within 1-1.5 min.
With very slow sweeping motions with downward pressure, the right forehead, temple, medial and lateral
cheek, and jawline (maximum of 10 cm × 10 cm area) were treated, as shown in [Figures 1 and 2]. Settings
for the forehead and temple were power of 90 and duty factor of 80. Settings for the cheek and jawline were
power of 90 and duty factor of 100. After reaching therapeutic temperature, these areas were treated for a