Caught In The Middle

Microneedling is quickly becoming a go-to procedure for skin rejuvenation, and the addition of radiofrequency (RF) dramatically improves upon its already impressive results—without increasing the downtime.

More than a marriage of convenience, the union is really about taking two procedures that have their place in our non-surgical treatment armamentarium and combining them to increase the robustness of results. Several RF microneedling devices are currently available, including Syneron-Candela’s Profound, Inmode’s Fractora, and Lutronic’s Infini.

Proper patient selection is the best way to maximize benefits of RF microneedling in an aesthetic practice. In my opinion, Profound (formerly known as ePrime) is best suited for skin tightening, while the gentler and kinder Fractora and Infini can improve upon fine lines, wrinkles, and acne scars with some residual improvements seen in skin texture. If a patient comes in with acne scars, for example, I consider ablative or non-ablative fractionated laser resurfacing or RF microneedling with the Infini or Fractora. Certain things may tip the scale in favor of one or the other. For example, microneedling is color blind and thus less likely to cause pigment changes. If a patient is at risk for hyper- or hypopigmentation, RF microneedling will make more sense. Overall skin quality plays a role in the decision-making process, too. If a patient has fine wrinkles, it may tip the scale toward RF microneedling, but if their wrinkles are much deeper, we may consider fractionated ablative laser resurfacing.

The ability to withstand and/or accept downtime is also another factor in the treatment decision. Fractionated non-ablative laser resurfacing has the least downtime, but involves more treatments than RF Microneedling. The tradeoff, however, is the results. RF Microneedling will produce noticeable improvements in half the number of treatments as non-ablative fractionated laser resurfacing—three treatments versus five or six, respectively. On the other end of the spectrum, ablative fractionated laser resurfacing is a one-and-done treatment, but it does necessitate significantly more downtime. After RF Microneedling, patients may experience two to five days of downtime marked by oozing, bleeding, and pinkness of the skin. By contrast, fractionated ablative laser resurfacing patients will experience a more pronounced recovery period—with symptoms lasting a week or longer.

There may also be differences in the anesthesia method chosen. RF Microneedling requires local anesthesia or nerve block, but we can now achieve quick and effective anesthesia with multiple needles spaced 1cm apart attached to one syringe, which improves both patient comfort and anxiety levels.

In sum, fractionated non-ablative laser resufacing is the gentlest for acne scarring, RF microneedling is the middle of road, and ablative fractionated laser resurfacing remains the most aggressive treatments we offer. It is important to discuss the benefits and risks of all of these treatment options with patients as each comes with their own fair share of both.

RF Microneedling fits nicely into the menu of choices we can offer our patients today. The machines are less expensive than laser technology, and they have demonstrated effectiveness. In some states, these treatments can be delegated to properly trained physician extenders. Even where permitted, however, I would be cautious about delegating Profound because of the deep and relatively large zones of injury involved. Precision is important, as the needles must enter the skin at very exact angles to a very specific depth to maximize benefits and minimize risks.

Dr. Hruza is an Adjunct Professor of Dermatology at St. Louis University in St. Louis, MO andDirector of the Laser & Dermatologic Surgery. He is incoming President-Elect of the American Academy of Dermatology and Past President of the American Society for Laser Medicine and Surgery, the St. Louis Metropolitan Medical Society, and the American Society for Dermatologic Surgery.

Dr. Hruza originally presented this talk during Cosmetic Surgery Forum 2016 in Las Vegas.