Multipass Vector (Mpave) Technique with NonablativeRadiofrequency to Treat Facial and Neck LaxityERIC FINZI, MD, PHD, AND AMY SPANGLER, MPAS, PA-C

Dermatology and Cosmetic Surgery Associates, PA, Greenbelt, Maryland

BACKGROUND. Redundant facial and neck skin is a major featureof aging and historically has been corrected surgically. Recently,monopolar radiofrequency application has been introduced fornonablative tissue tightening of skin by volumetric heating of thedeep dermis. It has been able to improve neck and cheek laxityand periorbital rhytides and to elevate eyebrows. However, ques-tions remain as to the ideal parameters needed to optimize theuse of radiofrequency.OBJECTIVE. To determine the safety and report on the efficacy ofa radiofrequency application that involves a multipass vector(mpave) technique to target facial and neck skin laxity.METHODS. Twenty-five patients (skin types I to V) with mild tosevere facial and neck laxity received one treatment session withmonopolar radiofrequency. Treatment parameters, adverseevents, and digital photographs were recorded. All patients weretreated with a multipass vector technique consisting of four tofive passes targeted over areas of skin that would most improve

facial laxity. The multipass vector (mpave) treatment approachis described. Energy levels ranged from 62 to 91 J/cm2 per pulse.RESULTS. All patients experienced some immediate erythema andedema, which had completely resolved in most patients within 48hours. No scarring or dyspigmentation was noted on follow-upat 6 and 12 weeks. Photographic analysis of pre- and post-treatment digital images revealed cosmetic improvement in facialand neck laxity in 96% of patients. The majority of patientsdemonstrated a moderate or better improvement. Stacked pulsesin the submental region were shown to reduce fat.CONCLUSIONS. The direct application of monopolar radiofre-quency to facial and neck skin using a multipass vector (mpave)treatment approach was safely tolerated in patients of all skintypes. Patient satisfaction correlated well with photographicanalysis, and the technique was shown to be efficacious for mostpatients.

© 2005 by the American Society for Dermatologic Surgery, Inc. • Published by BC Decker IncISSN: 1076–0512 • Dermatol Surg 2005;31:916–922.

ERIC FINZI, MD, PHD, AND AMY SPANGLER, MPAS, PA-C, HAVE RECEIVED NO FUNDING FOR THISSTUDY.

RADIOFREQUENCY HAS found many applications inmedicine.1–5 Recently, nonablative radiofrequency (Ther-maCool TC system, Thermage, Hayward, CA, USA) hasbeen introduced for facial skin tightening.6–16 US Food andDrug Administration approval has been given for treat-ment for periorbital rhytides, as well as cheek and necklaxity. This device causes deep dermal volumetric heatingsecondary to electric current resistance while using cryo-gen application to protect the epidermis.

Recent reports have shown improvement in periorbitalrhytides, eyebrow height, and cheek and neck laxity.8–16

However, questions remain about the efficacy and consis-tency of cosmetic improvement seen after radiofrequency.In addition, the optimal treatment protocol is unknown.We report here the direct application of nonablativemonopolar radiofrequency to facial and neck skin using amultipass vector (mpave) technique to treat facial and skin

laxity and show that it is consistently both safe and effi-cacious. We also demonstrate the use of stacked pulses toreduce unwanted fat.

Materials and Methods

Twenty-five patients with no history of face-lift, brow-lift,or blepharoplasty surgery were followed prospectively. Allpatients gave informed consent, and the study protocolconformed to the ethical guidelines of the 1975 Declara-tion of Helsinki. The treatment group included one man.Patient ages ranged from 33 to 68 years. Anesthesia andmild sedation were obtained in most patients with 1 to2 mg of lorazepam orally and 1 to 1.5 mg/kg of meperi-dine and hydroxyzine intramuscularly. The majority ofpatients still complained of moderate discomfort but wereable to tolerate the procedure. No postoperative care wasgiven. Patients were evaluated by standardized digital pho-tography preoperatively and 6 and 12 weeks postopera-tively. All preoperative and postoperative photographswere reviewed by the first author and independently, in ablinded fashion, by two physicians who were not part of

Address correspondence to: Eric Finzi, MD, PhD, Dermatology andCosmetic Surgery Associates, PA, Suite 504, 7701 Greenbelt Road,Greenbelt, MD 20770, or e-mail: efinzi@aol.com.

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the study. Improvement in facial laxity was assessed at 3months according to the following categories: no improve-ment, 1 to 25% improvement, 26 to 50% improvement,51 to 75% improvement, and 76 to 100% improvement.All patients were treated with the 1 cm fast tip Therma-Cool TC system.

Operative Technique

To determine the ideal plan for placement of pulses on theface and neck, patients were first examined in the uprightposition. Patients were viewed both frontally and at 45and 90 degrees. The skin was gently pulled in multipledirections to determine the most helpful vectors. In mostpatients, this resulted in two major vectors (Figure 1, Aand B). The inferior jaw and neck vector usually measuredabout 60 degrees, whereas the midface vector was 30 degrees, relative to an imaginary horizontal line drawnfrom the inferior root of the helix to the nose. After grid-ding of the entire face and neck, the inferior vector wasthen drawn with erasable Crayola markers in an expand-ing teardrop configuration starting from the preauricularregion. The teardrop configuration was used to minimizethe risk of causing a noticeable stepoff on the lower cheekbetween areas treated with single versus multiple passes.Thus, the largest teardrop received one complete pass,whereas the smallest teardrop received four passes.

The entire face and neck were initially treated with onecomplete pass; therefore, the smallest teardrop eventuallyreceived five passes. Treatment settings on the mid- andlower face varied from 73 to 85 J/cm2 (73–74 level, 1 cmfast tip) depending on patient tolerance. Figure 2 showsthe placement of mpave treatment areas on two patients.

To reduce the risk of asymmetry, after a pass wasapplied to one side, the identical area on the opposite sidewas then treated. The midface vector was designed toaddress the nasolabial fold. Two rows of pulses weretreated from the inferior root of the helix to themid–nasolabial fold. Three passes were applied to thenasolabial fold vector.

Attention was then turned to the eyebrow-foreheadarea. The skin superior to the eyebrows was stretchedsuperiorly to determine whether the entire eyebrow shouldbe lifted uniformly or if an elevation of the lateral relativeto medial eyebrow was desired. If a general eyebrow-liftwas desired, three columns of pulses symmetrically cen-tered over the mideyebrow were placed from the eyebrowto the scalp-forehead border (see Figure 2). When a lateraleyebrow-lift was desired, the three columns of pulses wereplaced more laterally but not beyond the temporal fusionline, to reduce the risk of fat atrophy. Three passes wereapplied at energies of 73 to 85 J/cm2 (73–74 level) to thecolumns on the forehead.

Figure 1. (A) Preoperative lateral view showing placement of the midface and inferior jaw and neck vectors. (B) Direction of the foreheadand eyebrow vector. (C) Preoperative oblique view showing teardrop configuration of the inferior jaw vector. The lateral and submental sub-divisions of the neck are seen. (D) Frontal view of the inferior jaw and submental subunits.

The neck region was divided into a submental (see Figure 1, S) area and a lateral area (see Figure 1, L). Treat-ments were applied at 68 to 85 J/cm2. If the submental areacontained significant fat in addition to skin laxity, twopasses were stacked without time delay to areas of desiredfat removal, at 62 J/cm2 (72 level). Attention was paid toensure placement of stacked pulses away from the thyroidgland. In addition, three more nonstacked passes wereapplied to the entire submental region. The lateral neck wastreated with three passes of two to four rows just inferior tothe mandible, depending on the degree of skin laxity.

Results

Figures 3 to 7 demonstrate typical results seen with thempave technique. In most patients, an observableimprovement was gradual, with maximal improvementnoted at 12 weeks. Dyspigmentation, burns, or scarringwas not noted in any patient. Postoperative bruising wasnot noted, but postoperative periorbital edema lasted aslong as 7 days in two patients. All patients were able toresume normal activities the following day. Two patientsexperienced temporary submental dysesthesia, which com-pletely resolved after 6 weeks.

Fourteen patients were treated with stacking of pulsesin the submental region. Typical fat reduction observedafter stacking is seen in Figures 3 and 6.

Figure 7 demonstrates a general eyebrow lift (C and D)versus a lateral eyebrow lift (A and B).

Review of photographs before and after treatmentrevealed that 96% of patients showed some clinicalimprovement, as judged by the primary author and twoindependent evaluating physicians. Three months aftertreatment, 16% of patients showed mild (1–25%)improvement, 56% of patients showed moderate(26–50%) improvement, 20% of patients showed excel-

lent (51–75%) improvement, and 4% of patients showedmarked (76–100%) improvement (Figure 8).

The single patient who failed to show any improvementwas 68 years of age. Patient satisfaction was excellent butuniformly so only after showing before and after photo-graphs to the patients.

Discussion

The gold standard for treatment of facial sagging has formany years been surgical-cervicofacial rhytidectomy in itsmany forms. Numerous variations exist for treatment ofdifferent facial areas, including the Webster-type face-lift,midplane, deep plane, endoscopic, and others.15–19 Many ofthese procedures have significant risk, along with down-time from 2 to 6 weeks. More recently, the S-lift and itsvariations have been developed in an attempt to minimizerisk and downtime.20,21 However, it still involves surgeryand downtime. Along with increasing patient demand forcosmetic rejuvenation procedures, there has been a strongdesire by our patients for minimal downtime and very low-risk procedures to improve facial skin sagging.

Several studies have documented subjective clinicalimprovement in brow elevation, eyelid skin flaccidity, andfacial and neck sagging.6–16 Ruiz-Esparza and Gomezreported skin tightening in 14 of 15 patients treated with asingle pass of radiofrequency treatment applied to thelower third of the face.8 A multicenter study of 86 patientsshowed modest clinical improvement in the periorbitalregion and brow in 80% of patients.11 Ruiz-Esparza treatedperiorbital skin in nine patients with one to three passes ofradiofrequency to improve lower eyelid flaccidity.14 Iyerand colleagues showed that 70% of their patients showedsignificant improvement after a single radiofrequency treat-ment, with greater improvement seen in those patients whoreceived multiple treatments over time.12

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Figure 2. (A) Preoperative oblique view of a patient demonstrating the forehead, midface, and inferior jaw vector. (B) Intraoperative view ofa patient after full-face gridding and initial drawing of facial vectors.

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Figure 3. (A) Preoperative lateral view. (B) Postoperative view at 6 weeks. (C) Preoperative frontal view. (D) Postoperative frontal view at 6 weeks.

Figure 4. (A) Preoperative frontal view. (B) Postoperative frontal view at 6 weeks. (C) Preoperative lateral view. (D) Postoperative lateral viewat 6 weeks.

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Figure 6. (A) Preoperative frontal view of patient 12. (B) Postoperative frontal view at 6 weeks of patient 12. (C) Preoperative frontal view ofpatient 20. (D) Postoperative frontal view of patient 20 at 3 months.

Figure 5. (A) Preoperative frontal view. (B) Postoperative frontal view at 3 months. (C) Preoperative oblique view. (D) Postoperative obliqueview at 3 months.

Hsu and Kaminer evaluated the lower face and neckafter a single radiofrequency procedure.6 They observedthat younger patients who were treated with higher energylevels demonstrated greater clinical improvement. How-ever, only one-third of patients were very satisfied with theresults. Alster and Tanzi similarly observed that 5 of 50patients who received a single-pass radiofrequency treat-ment did not demonstrate any clinical improvement.11

These five patients were all older than 62 years of age, sug-

gesting that there may be an age-related cutoff forradiofrequency-induced skin tightening. The rest of theirpatients did experience clinical improvement; however, theresults seen, as in other studies, were modest.

Nahm and colleagues demonstrated an average brow ele-vation of 2 to 4 mm, superior palpebral crease elevation of1.9 mm, and 22% jowl surface area improvement in a split-face study after single-pass radiofrequency treatment of theforehead.13 These results confirmed objectively that radiofre-quency could improve eyebrow, eyelid, and jowl aging.

However, many questions remain about optimal treat-ment parameters for facial skin tightening. For example,the safety and efficacy of multiple radiofrequency passesduring a single treatment session have not been well doc-umented. Ruiz-Esparza and Gomez suggested the idea ofusing multiple passes,8 and Ruiz-Esparza safely treatedtwo patients with three passes of radiofrequency to peri-orbital skin.14 Whether additional passes are more effica-cious is not known. Another important question is theconsistency of results seen after a single treatment. Also,we do not know what the ideal energy levels for treatmentare. Ruiz-Esparza suggested that lower fluences may workas well as higher fluences,14 but direct comparisons havenot been reported. How does it vary according to treat-ment area? Should we base our energy level on patient-perceived pain, or are there protocols that will work con-sistently in most patients?

As an initial step toward improving the consistency andefficacy of radiofrequency-induced skin tightening, wedeveloped a standardized treatment algorithim that is alsotailored to the specific clinical defects that need to beaddressed to optimize improvement of facial and neckaging. Using the mpave technique, 96% of our patientsexperienced clinical improvement, which was easily

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Figure 7. (A) Preoperative frontal view of patient 22 prior to lateral eyebrow lift. (B) Postoperative view of patient 22 at 3 months. (C) Pre-operative frontal view of patient 11 prior to general eyebrow lift. (D) Postoperative frontal view of patient 11 at 3 months.

A B

C D

Figure 8. Percentage of patients showing different degrees ofimprovement based on independent photographic evaluation at 3months.

observed clinically and photographically. Eighty percent ofpatients had moderate (26–50%) or better improvement.This treatment approach was able to address upper, mid-,and lower face and neck sagging using slightly lowerenergy levels and multiple (four to five) directed passes tocause significant clinical improvement.

We reasoned that stacking of pulses without a timedelay would impair heat dissipation in the deeper tissues,whereas the cryogen cooling spray safely protected theepidermis. It was thought that deeper heat penetrationwould cause damage to adipose tissue. Our results to datehave shown that unwanted submental fat can be reducedwith the use of stacking pulses. Additional controlled stud-ies with larger numbers of patients are needed to deter-mine the general applicability and safety of this approach.

Electron microscopic studies of human skin treatedwith radiofrequency have revealed damage to collagen fib-rils after a single pass of radiofrequency.22 More basic sci-ence studies on the effect of radiofrequency applied tohuman skin are needed to confirm this and to help withdetermining ideal treatment protocols.

Prior to the initiation of this study, we observed fatatrophy on the temple in one patient treated at 134 J/cm2.Subsequently, we elected to increase the safety margin bytreating all patients at 91 j/cm2 (74.5 level, fast 1 cm tip)or lower on the face and neck. In addition, we lowered themaximal treatment level on the temple to 68 J/cm2

(72.5 level, fast tip, 1 cm). We have not observed anyunwanted fat atrophy in 60 patients (not in this study)treated with these lower energy levels.

Despite pretreatment medication with 1 or 2 mg oflorazepam orally and 1 mg/kg of both meperidine andhydroxyzine intramuscularly, most patients still foundradiofrequency treatments to be painful but tolerable. Thenumbers of patients are too small to warrant definitiveconclusions regarding the ideal energy level. For example,we do not know how the level of pain experienced by indi-vidual patients relates to their final results. Further workis clearly needed to determine appropriate energy levelsthat allow for maximal patient safety and comfort alongwith treatment efficacy.

In summary, a multipass vector (mpave) techniqueusing monopolar radiofrequency produces significant clin-ical improvement in facial and neck laxity with few poten-tial side effects and little downtime.

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