M i c ro n e e d l i n g O p t i o n s f o r

S k i n Re j u v e n a t i o n ,
I n c l u d i n g N o n – t e m p e r a t u re -
c o n t rol l e d F r a c t i o n a l
M i c ro n e e d l e Ra d i o f re q u e n c y
Tre a t m e n t s
Dana Alessa, MDa, Jason D. Bloom, MD, FACSb,c,*

KEYWORDS
 Microneedling  Radiofrequency  Radiofrequency microneedling  Acne scars  Skin rejuvenation

KEY POINTS
 Conventional microneedling and radiofrequency microneedling are considered safe and effective
methods for skin rejuvenation, if performed appropriately.
 Treatments are safe for all skin types because, unlike lasers, they are chromophore blind.
 Treatments are usually well tolerated with topical anesthesia and with minimal side effects.
 The proper device selection and treatment parameters are essential keys to successful therapies.
 There are expanding indications for these devices, including but not limited to hyperhidrosis, cellu-
lite, striae.

INTRODUCTION Histologic studies have shown increased new

collagen and elastin after the use of microneedling
The use of microneedling for aesthetic purposes tools, such as the original Dermaroller. When using
has been well studied over the years. Most of the such devices, small zones of injury are created in
documented work using this technology has been the papillary dermis, which then undergo the
to study acne scars; however, its efficacy in other wound healing process and cascade, resulting in
areas, such as surgical or traumatic scars, mel- improved scars and wrinkles. The nonablative
asma, striae, androgenetic alopecia, and skin reju- (sparing the epidermis) nature of microneedling
venation, has also been studied. Radiofrequency makes it ideal for all skin types with almost no
(RF) microneedling (RFMN) is a newer technology risk for hyperpigmentation.1
that has shown promising results for skin rejuvena- Radiofrequency microneedling functions by
tion and acne scars and is discussed in this article. delivering RF energy at a selected tissue depth us-
ing a multiple needle probe array. In general, RF
MECHANISM OF ACTION devices use electromagnetic energy in order to
Percutaneous collagen induction is the basic the- generate heat in tissues through the rapid move-
ory behind all forms of microneedling technology. ment of charged particles. This heat ultimately
facialplastic.theclinics.com

Disclosures: None.
a
King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), PO Box 3660, Riyadh 11481, Saudi Arabia;
b
Bloom Facial Plastic Surgery, Two Town Place, Suite 110, Bryn Mawr, PA 19010, USA; c Department of Otorhi-
nolaryngology—Head & Neck Surgery, University of Pennsylvania, 3400 Civic Center Blvd, South Pavillion 3rd
Floor, Philadelphia, PA 19104, USA
* Corresponding author. Bloom Facial Plastic Surgery, Two Town Place, Suite 110, Bryn Mawr, PA 19010.
E-mail address: [email protected]

Facial Plast Surg Clin N Am 28 (2020) 1–7

https://doi.org/10.1016/j.fsc.2019.09.001
1064-7406/20/Ó 2019 Elsevier Inc. All rights reserved.
2 Alessa & Bloom

leads to collagen denaturation and the shrinkage improved scars on the treatment side compared
or contraction of tissue when a critical temperature with baseline, whereas no significant change was
is reached (65 C to 75 C).2 noted on the control side.11
Clinical and histologic studies have shown the Compared with nonablative fractional laser
efficacy of transepidermal nonablative RF for tis- treatment of acne scarring, 2 randomized
sue remodeling; neocollagenesis through collagen controlled trials showed no significant difference
fibril contraction and clinical improvement was in efficacy between microneedling alone or com-
noted in the periorbital area (decreased periorbital bined with 20% trichloroacetic acid and nonabla-
wrinkles, improved brow position), midface/lower tive fractional laser (1540 nm and 1340 nm).12,13
face (nasolabial folds, marionette lines, jowls, Split-face controlled trials comparing micronee-
laxity under the chin), and neck laxity.3–6 Histologic dling alone or with vitamin C with microneedling
analysis of skin tissue treated with RFMN for acne combined with platelet-rich plasma (PRP) for
and acne scars also showed increased collagen acne scars showed superior results in the latter
deposition through upregulated transforming combined group (microneedling 1 PRP). These re-
growth factor beta, and decreased inflammatory sults are produced by the combined effects of
markers such as nuclear factor-kB and inter- growth factors triggered by cutaneous wounds
leukin-8.7 from microneedling, as well as growth factors con-
In contrast with lasers, which are used to target tained in PRP.14–16
selective chromophores in tissues, RF functions
by nonselective tissue heating (independent of tis- MICRONEEDLING: TRANSEPIDERMAL DRUG
sue chromophores), making it safer in darker skin DELIVERY
types.8
Many studies have investigated the idea and effi-
Microneedling cacy of using microneedling as a tool to enhance
The reported safety and efficacy of microneedling drug delivery into the skin.
treatments initially made it an attractive procedure In a randomized controlled trial of 100 male sub-
for patients looking for an effective aesthetic pro- jects with moderate to severe androgenetic alope-
cedure with minimal downtime. cia, subjects randomized to the treatment group
The tools used for these procedures include rol- receiving microneedling combined with the topical
lers and electric pen devices with disposable tips. application of minoxidil had statistically significant
During the treatment, the device is held perpendic- superior results in hair growth compared with sub-
ularly and rolled or glided over the skin until jects receiving minoxidil only.17
pinpoint bleeding is appreciated. Needle penetra- A controlled trial investigating the treatment of
tion depths are adjusted by the provider, depend- melasma was conducted among 20 subjects
ing on the particular area and skin thickness to be who had split-face treatment; 1 side had micro-
treated, with deeper needles for thick skin and needling combined with a depigmenting serum
shorter needle depth for thin or delicate skin, and the other side had the serum alone. The re-
such as the periorbital area.9 sults of this study showed a statistically signifi-
SkinPen (Bellus Medical) is the first US Food and cant reduction in the Melasma Area and
Drug Administration (FDA)–cleared microneedling Severity Index score in the combined treatment
device for facial acne scars. side compared with the side treated with the
serum alone.18
MICRONEEDLING FOR ACNE SCARS
MICRONEEDLING FOR SKIN REJUVENATION
One of the earliest microneedling studies was (LAXITY AND WRINKLES)
done with a rolling tool (Dermaroller) that has 94
microneedles at the tip, with depth varying from Clinical and histologic assessments were done in
0.1 mm to 1.3 mm, depending on the amount of 10 patients who underwent 6 microneedling treat-
pressure applied to the skin. Thirty-two subjects ments using a Dermaroller and the results
with rolling-type acne scars received 2 treatments, showed significant improvement in wrinkles,
8 weeks apart. Results showed that all subjects skin texture, and overall satisfaction as well as
had greatly reduced scar severity.10 increased collagen and tropoelastin in biopsy
In a randomized controlled trial of 15 subjects specimens.19
with acne scars, 1 side of the face served as the Statistically significant improvement in the signs
treatment side and received 3 microneedling treat- of photoaging (wrinkles, laxity, and texture) was
ments, whereas the other side of the face served also seen in another study using a motorized
as the control. Results showed significantly microneedling device.20
 Microneedling Options for Skin Rejuvenation 3

Radiofrequency Microneedling subcutaneous adipose tissue, and 24 insu-

lated pins with depths of more than 4000 mm.
The technology
 Intensif (Endymed, Caesarea, Israel) was the
Not all RFMN devices are equal. There are 2
first FDA-cleared RFMN device. The needle
different types of needle used in these devices:
tip has 25 noninsulated gold microneedles
noninsulated microneedles delivering energy
with needle depths ranging from 0.5 mm to
throughout the needle length, and insulated micro-
5.0 mm, power 0 W to 25 W, and pulse dura-
needles delivering energy only at the needle tip in
tion 50 to 200 milliseconds.
the dermis, thus protecting the epidermis from
 INFINI (Lutronic) delivers bipolar RF energy
heat and thermal damage.
with 49 insulated microneedles in the tip.
Most devices deliver bipolar RF energy where
Depths range from 0.5 mm to 3.5 mm, power
the current is traveling between positive and nega-
2.5 W to 50 W, and pulse duration 10 to
tive electrodes on the tip, limiting the current in the
1000 milliseconds. Genius is Lutronic’s
treated area for a controlled distribution. With
second-generation RFMN device, with propri-
monopolar RF, the current is traveling between
etary technology that allows more precise
the active electrode tip in the treated area and a
needle and energy delivery through contin-
grounding electrode at a distant body location,
uous impedance monitoring for optimal
allowing deeper or improved energy penetra-
treatment.
tion.21,22 Compared with monopolar RF, bipolar
 Vivace (Cartessa) offers both insulated and
RF requires less energy and provides less energy
noninsulated 36-microneedle tips. Depths
depth penetration because of the smaller and con-
range from 0.5 mm to 3.5 mm, power 30 W
tained area of current passage.2
to 70 W, and pulse duration 100 to 800 milli-
seconds. The system also delivers LED
Some radiofrequency microneedling devices on (light-emitting diode) light at the same time
the market with 2 options: blue light for an antibacterial
effect and red light for collagen stimulation.
 INTRAcel (Jeisys, South Korea) device offers
both monopolar and bipolar options. The tip Table 1 shows a comparison between the devices
is composed of 49 insulated microneedles based on a compilation of physician surveys inde-
with 4 needle depth options: 0.5 mm, pendently conducted using a fixed survey format
0.8 mm, 1.5 mm, and 2.0 mm. and defined criteria by ZALEA. These results do
 Fractora (InMode, Israel) has multiple alterna- not reflect ZALEA’s testing or opinion.
tives for tips with different densities, lengths, The first use of an RFMN device was studied by
and insulation options that function through Hantash and colleagues23,24 using a bipolar de-
bipolar technology: deep dermal, low- vice that featured temperature and impedance
density, 3000-mm, 24-pin tip; deep and sub- transcription, allowing the delivery of energy at a
dermal low-density, 3000-mm silicon coated preselected temperature and depth, respectively.
24-pin tip; and mid-dermal, high-density, Histologic evaluation of biopsy specimens showed
600-mm, 60-pin tip. Morpheus8 is the newest areas of collagen denaturation (RF thermal zones)
RFMN device, with deeper needle depths followed by dermal remodeling through neocolla-
that spare the dermis for action in the genesis and neoelastogenesis.

Table 1
Comparison between the devices based on a compilation of physician surveys independently
conducted using a fixed survey format and defined criteria by ZALEA

INTRAcel INFINI Fractora Intensif

ZALEA Physician Editors Rating 4 out of 5 4 out of 5 3 out of 5 3 out of 5
Overall Rating 7.9 out of 10 7.5 out of 10 7.2 out of 10 6.3 out of 10
Marketing Claims 7.7 8.3 8.5 7.2
Peer-reviewed Literature 6.6 7.7 7 6
Consistency of Results 8.6 8.4 8.8 7.6
Comfort Level 8.1 5.1 3.5 4.2
Overall Satisfaction 8.4 7.8 8 6.4

These results do not reflect ZALEA’s testing or opinion.

4 Alessa & Bloom

RADIOFREQUENCY MICRONEEDLING FOR of 19 patients (57.9%) had at least 1-grade

ACNE AND ACNE SCARS improvement and, 3 months following the third
session, 9 patients were again evaluated and all
Most of literature on RFMN to treat acne scarring showed at least 1-grade improvement. Nine sub-
was in patients with dark skin types, given the jects (47.4%) also showed improvement in facial
increased safety profile and lower risk for postin- dyschromia.26
flammatory hyperpigmentation (PIH) with such Encountered side effects of these procedures
treatments. included pain, erythema, edema, and PIH, all of
In 2 of the studies that investigated the efficacy which were transient (Fig. 1).
and safety of RFMN for acne scars in subjects with Further acne-related research, investigating
skin types III to V, the assessments were done us- the improvement in active acne lesions and
ing the Goodman and Barron’s Global Qualitative acne-related postinflammatory erythema with
Acne Scarring System (1, macular; 2, mild; 3, mod- RFMN, was performed in darker-skinned pa-
erate; 4, severe). One had 31 subjects with mixed tients. The results of those studies support the
types of acne scars and these patients had 4 treat- evidence that treatment with RFMN produced
ments separated 6 weeks apart, using the INFINI decreased inflammation. The results of 3 INTRA-
device. Three months after the last treatment cel treatments on 25 subjects with moderate to
was the final evaluation of results. In the 14 sub- severe acne showed a 90.11% decrease in in-
jects with a baseline of grade 4, 12 (85.71%) flammatory acne, a 76.46% decrease in nonin-
showed a 2-grade improvement and 2 (14.28%) flammatory acne, and a 36.99% decrease in
showed a 1-grade improvement. Of the remaining sebum excretion.27 The INFINI device was used
17 subjects with a grade 3 baseline score, 13 in a related study for acne-related postinflamma-
(76.47%) showed a 2-grade improvement and 4 tory erythema in which 25 subjects in the treat-
(23.52%) showed a 1-grade improvement.25 The ment group receiving 2 RFMN treatments were
other study had 19 subjects who received 3 compared with 27 subjects in the control group
monthly treatments with the Intensif device. An receiving oral or topical therapy. Compared
evaluation of the treatments occurred 1 month with the control group, the treatment group
following 3 separate treatment sessions. Eleven showed statistically significant improvement in

Fig. 1. Before and 1 month after 3 INTRAcel treatments for acne scars. (Courtesy of Jeisys Corporation, Seoul, KR;
with permission.)
 Microneedling Options for Skin Rejuvenation 5

the investigators’ global assessment score, as RADIOFREQUENCY MICRONEEDLING FOR

well in objective assessment of erythema with SKIN REJUVENATION (LAXITY AND
both photometric device and digital software. WRINKLES)
Histologic studies showed decreased vascu-
larity, inflammation, and inflammatory markers Another large area of interest in which RFMN is
in the treatment group.28 Side effects reported beginning to play a large role is in the improvement
were pain, erythema, bleeding, scaling, and of skin laxity and texture through skin remodeling
crusting, which all resolved in a few days to and collagen stimulation.
1 week (Fig. 2). In a multicenter trial, the midface and lower face
Compared with transepidermal bipolar RF, a were treated with the Intensif device to assess lift-
randomized clinical trial of 20 subjects with mild ing, tightening, and wrinkle reduction. Forty-nine
to moderate acne and acne scars was conducted subjects (skin types II–IV) received 3 monthly
and subjects had split face treatment: 1 side with RFMN treatments on the cheeks, submandibular
RFMN and the other side with bipolar RF. After 2 area, and the neck. Subject evaluation was done
monthly treatments, results showed that RFMN 3 months after the last treatment to assess lower
was more effective in improving acne scars, and face lifting and skin tightening. The Global
showed a reduction in acne lesions and sebum Aesthetic Improvement Scale (GAIS) was used
excretion.7 and results showed that 100% of subjects had
The results of an efficacy trial comparing RFMN improvement and 65% had significant improve-
with a 1550-nm Er:glass fractionated laser in the ment. For wrinkle reduction and improvement of
treatment of acne scars showed that both groups skin texture, the Fitzpatrick Wrinkle and Elastosis
had statistically significant improvement Scale was used and results showed significant
compared with baseline. Although the laser group reduction from baseline (the average Fitzpatrick
showed superior results, there was no significant scores were 3.5  1.66 at 3 months compared
difference between the 2 groups. However, more with 5.04  1.22 at baseline).30
side effects were noted in the laser group (pain, er- In another study, Lyons and colleagues31 inves-
ythema, edema, dryness), and other side effects, tigated the efficacy of RFMN for the improvement
such as acne and PIH, were only reported in the of wrinkles and skin laxity of the décolletage area.
laser group.29 Twelve subjects received RFMN treatment every

Fig. 2. Before and 1 week after 2 INTRAcel treatments for active acne. (Courtesy of Jeisys Corporation, Seoul, KR;
with permission.)
6 Alessa & Bloom

Fig. 3. (A) Before and (B) 30 days after 1 treatment with the Genius device for chest wrinkles. (Courtesy of Lu-
tronic Corporation, MA, USA; with permission.)

3 weeks for a total of 3 treatments, using the Inten- treatment for scars, wrinkles, and skin laxity. Plast
sif device. One month following the last treatment Reconstr Surg 2008;121(4):1421–9.
was the evaluation using both the GAIS and 2. Arnoczky SP, Aksan A. Thermal modification of con-
patient-reported satisfaction. Results showed nective tissues: basic science considerations and
that 67% of subjects had at least a 1-point GAIS clinical implications. J Am Acad Orthop Surg 2000;
improvement and 80% of subjects were at least 8(5):305–13.
slightly satisfied31 (Fig. 3). 3. Zelickson BD, Kist D, Bernstein E, et al. Histological
A study done in Japan, in which 20 patients and ultrastructural evaluation of the effects of a
received 1 RFMN treatment to the face, showed radiofrequency-based nonablative dermal remodel-
that there was a significant volumetric reduction ing device: a pilot study. Arch Dermatol 2004;
and skin tightening of the lower two-thirds of the 140(2):204–9.
face 6 months after the treatment when evaluated 4. Fitzpatrick R, Geronemus R, Goldberg D, et al. Multi-
by three-dimensional volumetric assessment. center study of noninvasive radiofrequency for peri-
Ninety-percent of patients were satisfied or very orbital tissue tightening. Lasers Surg Med 2003;
satisfied with the results.32 Twelve months after 33(4):232–42.
the treatment, 15 of the study subjects were eval- 5. Alster TS, Tanzi E. Improvement of neck and cheek
uated and showed significant volume reduction in laxity with a nonablative radiofrequency device: a
the nasal and perioral area, proving the long- lifting experience. Dermatol Surg 2004;30:503–7.
lasting effect of RFMN.33 6. Fritz M, Counters JT, Zelickson BD. Radiofrequency
When using RFMN for skin rejuvenation, studies treatment for middle and lower face laxity. Arch
reported a similar side effect profile to RFMN used Facial Plast Surg 2004;6(6):370–3.
for acne scars: transient erythema, edema, and 7. Min S, Park SY, Yoon JY, et al. Comparison of frac-
pain. tional microneedling radiofrequency and bipolar ra-
Topical anesthesia is usually sufficient to pre- diofrequency on acne and acne scar and
vent pain associated with the RFMN procedure. investigation of mechanism: comparative random-
Most studies referenced in this article reported ized controlled clinical trial. Arch Dermatol Res
the use of topical anesthetic cream for 30 to 2015;307(10):897–904.
60 minutes before the procedure,26–33 and 1 8. Lee HS, Lee DH, Won CH, et al. Fractional rejuvena-
study25 used topical anesthesia as well as nerve tion using a novel bipolar radiofrequency system in
blocks. Asian skin. Dermatol Surg 2011;37(11):1611–9.
9. Alster TS, Graham PM. Microneedling: a review and
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