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MAKING WAVES 26 MAY/JUNE 2016 | Med Esthetics been reached," says Dr. Munavalli. "For microneedle RF devices, having a thermocouple to monitor the temperature generated by the pairs of needles in the specifi c array is necessary to accurately deliver energy. You must be able to adjust energy pulse and depth of needle penetration into the skin in order to heat the appropriate level of the dermis. Cost of disposables should also be considered as these are typically multi-treatment regimens." Be aware that treatment-related pain can be an additional issue. "When purchasing, understand that pain during the procedure can be a limiting factor with some of these needling devices," says Dr. Kaufman. "Since a few of them have been too painful to use without regional anesthesia, be sure to demo the units to see which ones are tolerable." Today, there are multiple fractional RF devices available. Dr. Munavalli uses the eMatrix and the Lutronic Infi ni, which was FDA approved in July 2013. Dr. Ross has three systems in his practice: the Infi ni, the Invasix Fractora and the Intensif. Dr. Kaufman currently uses the Infi ni. "The Infi ni has adjustable needles reaching depths of up to 3.5mm. In addition to reaching signifi cantly deeper into the skin where the collagen production actually takes place, the needles are insulated except at the tips where energy is released in a very precise manner," she says. The needles are also thinner than those in many devices—just 200 µ m in diameter. It offers a maximum power of 50W at level 20 and exposure times ranging from 10ms to 1,000ms. Dr. Sadick uses both the Venus Viva (Venus Concept) and the Intensif. "I prefer non-insulated needles, because I fi nd there is less bleeding and bruising," he notes. The Intensif received FDA approval in March 2014. The handpiece, which works with the EndyMed PRO device, utilizes an array of 25 sterilized, gold-plated microneedles to deliver RF energy in a fractional pulse mode using a unique algorithm. Practitioners can adjust the depth of needle penetration, energy level and pulse duration over the course of the treatment. The ability to combine the Intensif handpiece with the existing range of 3DEEP skin tightening and fractional skin resurfacing handpieces allows providers to treat multiple concerns with one system. A multicenter study presented at the 74 th annual meet- ing of the American Academy of Dermatology by Michael Gold, MD, et al, showed that 100% of 48 patients treated with the Intensif saw improvement in skin texture and fi ne lines and wrinkles following three treatments to the face and neck; 86% of patients reported that the procedure met their expectations. The newest device, the Venus Viva, was approved in May 2015. The Viva combines Nanofractional RF and proprietary SmartScan technology in a 160-pin array, delivering 62mJ per pin up to 500 µ deep. Varying energy density enables both epidermal ablation and dermal coagulation for effective skin resurfacing with minimal pain. The Venus Viva is portable, boasting the largest variable treatment area and highest heat capacity in the industry, consistent selectional dermal heating and controlled coagulation. COMBINATION TREATMENTS ENHANCE RESULTS A signifi cant benefi t to fractional RF devices is that they can be used in combination with other modalities to offer optimal outcomes. "At times we like to combine the fractional RF with something like IPL that will get rid of skin dyschromia and small broken vessels. Improving the overall look of the skin helps patients recognize the skin tightening, and we have also found greater patient satisfaction when we offer RF in combination with IPL," says Dr. Ross. "We use fractional microneedle RF right after IPL for red and brown spots. The patient sees immediate results from the IPL and after a time sees tightening from the RF." Dr. Sadick notes that fractional microneedle RF can be used to deliver platelet-rich plasma (PRP) or drugs into the dermis. He also uses the device in conjunction with some fi llers. At least one small study (Seo, et al, J Cosmet Laser Ther, 2013) has shown that fractional microneedle RF can be combined with stem cell-conditioned media to improve skin rejuvenation. Fifteen women were included for a split- face comparative study with a blinded response evaluation. One side of each subject's face was treated with fractional RF alone, and the other side was treated with fractional RF plus stem cell-conditioned media. Patients received three sessions at four-week intervals. The stem cell-conditioned media provided a synergistic effect, signifi cantly improving skin roughness, and histologic examination revealed a marked increase in dermal thickness and collagen content. Side effects were minimal. Manufacturers are also working to combine RF with other types of energy. For example, Israeli-based Pollogen launched the Pollogen Divine at Cosmoprof Asia in November 2015. The Divine adds ultrasound to its fractional RF microneedle platform, which improves the absorption of active ingredients. Pollogen was recently acquired by Lumenis, which has not released information on when, or if, the device might be available in the U.S. But the growth of fractional RF devices and treatments in the U.S. suggests that we will continue to see new and next-generation devices designed to provide better results for a broad range of indications. Linda W. Lewis is the contributing editor of MedEsthetics.