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DETAILS 26 JULY/AUGUST 2017 | Med Esthetics TREATMENT ZONES AND TEMPERATURES We divided the periorbital area into six cosmetic zones, defi ned as the treatment zone (Image 1). We found that treating two zones at one time allowed for more controlled heat distribution and delivery. This eliminated the need to stop and start treatment in order to remain in the optimal temperature window, defi ned as an epidermal tempera- ture of 40° to 42° C. This target was based on published literature showing temperature levels to be 20° warmer in the dermis as compared to the monitored epidermal temperature. 4 We treated each area—two cosmetic zones per area—for four minutes using multiple passes. The total session time was 12 minutes. Each patient received three treatments spaced 3-4 weeks apart. Epidermal tempera- ture was monitored throughout treatment using a handheld Fluke infrared temperature sensor. THE PROCEDURE To begin treatment, we cleansed the skin and applied disper- sion gel to allow smooth movement of the 10mm GlideSafe handpiece. The handpiece has a pressure-sensitive safety feature enabling the clinician to deploy RF energy only when the tip is compressed, thus preventing the risk of arcing and epidermal burns. The 10mm tip allowed for maneuver- ability and access to the skin just below the brow, which was digitally retracted upward over the supraorbital bone for treatment and downward at the infraorbital region to allow for more of the skin closer to the lid margin to be treated. We began treatment at the lateral canthal area (marked 1) and supraorbital area (marked 2); followed by areas 3 and 4. We ended by oscillating back and forth from area 5 to area 6 as this infraorbital region is the most sensitive. Each of the paired regions was treated for four minutes using a continu- ous, concentric motion to deliver a gradual, yet progressive and controlled thermal heating of the dermis. As the hand- piece was maneuvered with the operator's right hand, the left index fi nger glided beside the tip and functioned as both a physical distraction and as an assist to retract skin when necessary and disperse the generated heat. This allowed us to deliver a virtually painless treatment. No subject required epidermal cooling. RESULTS All 11 subjects completed the study. Patients reported very minimal discomfort (1-2), with more than 90% reporting a pain level of 1 out of 10 on a visual analog scale. Any mi nor erythema or edema present at treatment resolved within 30 minutes post treatment. The average GAS for rhytides pretreatment was 5.3, and 90 days post treat- ment it was 3.2. CONCLUSION Several energy-based treatment modalities can be used to revitalize the periorbital area, including nonablative and ablative lasers. These devices have a proven track record, but are associated with downtimes of 24 hours to 5 days, depending on the settings selected. A 12-minute, multi-pass 4Mhz monopolar RF treatment is an effective alternative for patients who want a zero downtime proce- dure to treat the periocular region. The treatment offers visible clinical results in three to fi ve treatments and can be utilized on any Fitzpatrick skin type. Raminder Saluja, MD, is a cosmetic surgeon who is board certifi ed in ophthalmology and fellowship trained in dermatologic cosmetic surgery. She is the founder of Saluja Cosmetic & Laser Center in Charlotte, NC. Contact her at salujalaser@gmail.com. References 1. Arnocsky, SP, Aksan A. "Thermal modifi cation of connective tis- sues: Basic science considerations and clinical implications." Am Acad Orthop Surg 2000; 8:305-13 2. Biesman, BS, Baker SS, Carruthers J, et al. "Monopolar radio- frequency treatment of human eyelids. A prospective, multicenter, effi cacy trial." Lasers Surg Med 2006:38:890-8 3. Zelicskon BD, Kist D, Bernstein E, et al. "Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: a pilot study." Arch Dermatol 2004;140:204-9. 4. Stamper. "The Pelleve Procedure: An Effective Method for Facial Wrinkle Reduction and Skin Tightening." Facial Plastic Surgery Clinic. 2011: May V (19): 2 PHOTOS COURTESY OF RAMINDER SALUJA, MD Results following three treatment sessions with nonablative RF energy. Treatments were spaced 3-4 weeks apart. Image 1. BEFORE AFTER TREATMENT AREAS