14.1 Introduction

In 2010, a small version of a bipolar radiofrequency device became available under IRB oversight for treatment of face and neck for skin and soft tissue laxity. At that time, the lack of a stromal collagen support matrix was not recognized as a root cause of apparent facial aging. Therefore, the development of this scarless facelift took several years. Initially, the device was used to augment treatment of focal laxity in conjunction with an open facelift. Those regions treated were regions known to be poorly corrected with traditional excisional techniques. The nasolabial fold, marionette lines, central submental, and jowl regions were initially targeted.

Patients were treated with the bipolar radiofrequency-based device over a five year period. The simple procedure included infusion of tumescent fluid followed by bipolar RF minimally invasive soft tissue tightening for a variety of indications. The majority of patients underwent radiofrequency-assisted treatment for the purpose of aiding an open or short scar facelift approach. This approach was also used for secondary facelifts, as central residual or recurrent laxity was noted frequently as a chief complaint.

14.2 Indications: Choosing a Patient

The ideal patient meets the following criteria:

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  Desires mild to moderate face lifting without the scars associated with a traditional skin excision technique.

  
  
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  The procedure can be used in both men and women.

  
  
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  Patients with limited recovery time may choose this technique as downtime is usually 2–3 days. Mild bruising and swelling may occur. Patients may return to work whenever the degree of swelling is acceptable, and residual bruising can be covered with makeup.

  
  
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  Compliance with wearing a support garment for 2–3 days initially, and for 2 weeks postoperatively at night will improve the outcome. In difficult cases combining a heavy face/neck with liposuction, or a secondary correction, the face and neck compression garment worn at night for a longer period can help mold the face and reduce contour irregularities. Removing stretch or tension at the treatment site improves the formation of collagen-binding of the tissue matrix over time.

  
  
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  Willingness to wait for improvement is also necessary; while significant improvement is noted at six weeks post-treatment, the optimal outcome may not be seen for 6–12 months.

  
  
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  The desire for avoidance of scars must be strong as improvement may be mild to moderate only.

14.3 Contraindications

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  Pregnant or nursing patients.

  
  
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  Patients with unrealistic expectations.

  
  
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  Unwillingness to comply with wearing of support garments or prolonged follow-up.

  
  
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  Severe facial skin laxity, or severe soft tissue laxity.

  
  
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  The presence of very thick skin, scars, or fibrosis from previous surgeries.

  
  
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  Obese patients.

14.4 Technique

Technique with this approach starts with good patient selection. If the problem you are hoping to correct is small enough to be effectively addressed with this procedure, then it can be considered. In first evaluating the patient, it is important to have an understanding of how much this procedure can accomplish. Localized bulges can be flattened, and some degree of focal skin ptosis and laxity can be improved. Predictability of outcome is a learned skill; it is best to start small when first attempting this procedure.

Tumescent fluid is infused as it would be for liposuction. Because the facial nerves could be at risk, more infusion is generally safer than just a little. Depending upon the area to be treated, I will inject 100–200 cc of standard tumescent solution per facial side, superficially, after marking the target regions in an upright position. The well-known trouble spots where the facial nerve becomes superficial are marked before tumescing, as these can become distorted after infusing. However, generally no liposuction is used. I prefer bipolar radiofrequency minimally invasive devices for this procedure, but monopolar RF can also be used. The external temperature is not allowed to exceed 35 degrees Centigrade. My maximum internal temperature is 55 degrees. Keeping settings safe ensures that adequate time on tissue can be achieved without damaging facial nerves or creating a burn. It is important to respect the small amount of tissue you are working with.

For best results, the entire skin envelope that has subcutaneous fat below it is treated ▶Fig. 14.1. I avoid the forehead as heating the frontalis muscle is not very effective and can be quite risky. Energy used can vary from 1–4 kilojoules per side, depending on the location and severity of the problem being treated. Especially for beginners, I would not recommend overtreatment. A flattened look will not be attractive. Overtreatment can cause a focal depression which can be irreversible.

Clinical endpoints include an audible crackling of tumesced tissue combined with a visible tissue response. In most regions, this will be a slight flattening of the protuberant area. Another visible change can be the erasure of fine lines or crepiness. Tissue will heat up quickly so if the maximum temperatures have been reached, move elsewhere. If the problem is severe and you are strongly inclined to retreat the same area, it is a good idea to let the soft tissue temperature return to normal before beginning a brief second session.

Access ports are usually made with an 18 gauge Nocor type needle, which is often used for subcision. A standard 18 gauge needle can be used as well. Because these needle pokes are usually very difficult to see, the placement of access ports should be performed with an eye for the clinical effect, not for the purpose of camouflage.

While access ports under the earlobe and near the modiolus inside the mouth have been popular, there is a greater risk of burns and facial nerve weakness due to the awkward angle or long reach needed with these approaches. When treating the jowl, it is essential to treat behind and within the region, rather than trying to reach all the way to the chin. When near a known motor or sensory nerve site, it is wise to stay superficial, not too close, and for a very brief amount of time. If you see motor activity of the lower lip while treating, immediately cease treatment and go elsewhere.