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

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

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
or contraction of tissue when a critical temperature
is reached (65 C to 75 C).2
Clinical and histologic studies have shown the
efficacy of transepidermal nonablative RF for tis-
sue remodeling; neocollagenesis through collagen
fibril contraction and clinical improvement was
noted in the periorbital area (decreased periorbital
wrinkles, improved brow position), midface/lower
face (nasolabial folds, marionette lines, jowls,
laxity under the chin), and neck laxity.3–6 Histologic
analysis of skin tissue treated with RFMN for acne
and acne scars also showed increased collagen
deposition through upregulated transforming
growth factor beta, and decreased inflammatory
markers such as nuclear factor-kB and inter-
leukin-8.7
In contrast with lasers, which are used to target
selective chromophores in tissues, RF functions
by nonselective tissue heating (independent of tis-
sue chromophores), making it safer in darker skin
types.8
Microneedling
The reported safety and efficacy of microneedling
treatments initially made it an attractive procedure
for patients looking for an effective aesthetic pro-
cedure with minimal downtime.
The tools used for these procedures include rol-
lers and electric pen devices with disposable tips.
During the treatment, the device is held perpendic-
ularly and rolled or glided over the skin until
pinpoint bleeding is appreciated. Needle penetra-
tion depths are adjusted by the provider, depend-
ing on the particular area and skin thickness to be
treated, with deeper needles for thick skin and
shorter needle depth for thin or delicate skin,
such as the periorbital area.9
SkinPen (Bellus Medical) is the first US Food and
Drug Administration (FDA)–cleared microneedling
device for facial acne scars.
MICRONEEDLING FOR ACNE SCARS
One of the earliest microneedling studies was
done with a rolling tool (Dermaroller) that has 94
microneedles at the tip, with depth varying from
0.1 mm to 1.3 mm, depending on the amount of
pressure applied to the skin. Thirty-two subjects
with rolling-type acne scars received 2 treatments,
8 weeks apart. Results showed that all subjects
had greatly reduced scar severity.10
In a randomized controlled trial of 15 subjects
with acne scars, 1 side of the face served as the
treatment side and received 3 microneedling treat-
ments, whereas the other side of the face served
as the control. Results showed significantly
improved scars on the treatment side compared
with baseline, whereas no significant change was
noted on the control side.11
Compared with nonablative fractional laser
treatment of acne scarring, 2 randomized
controlled trials showed no significant difference
in efficacy between microneedling alone or com-
bined with 20% trichloroacetic acid and nonabla-
tive fractional laser (1540 nm and 1340 nm).12,13
Split-face controlled trials comparing micronee-
dling alone or with vitamin C with microneedling
combined with platelet-rich plasma (PRP) for
acne scars showed superior results in the latter
combined group (microneedling 1 PRP). These re-
sults are produced by the combined effects of
growth factors triggered by cutaneous wounds
from microneedling, as well as growth factors con-
tained in PRP.14–16
MICRONEEDLING: TRANSEPIDERMAL DRUG
DELIVERY
Many studies have investigated the idea and effi-
cacy of using microneedling as a tool to enhance
drug delivery into the skin.
In a randomized controlled trial of 100 male sub-
jects with moderate to severe androgenetic alope-
cia, subjects randomized to the treatment group
receiving microneedling combined with the topical
application of minoxidil had statistically significant
superior results in hair growth compared with sub-
jects receiving minoxidil only.17
A controlled trial investigating the treatment of
melasma was conducted among 20 subjects
who had split-face treatment; 1 side had micro-
needling combined with a depigmenting serum
and the other side had the serum alone. The re-
sults of this study showed a statistically signifi-
cant reduction in the Melasma Area and
Severity Index score in the combined treatment
side compared with the side treated with the
serum alone.18
MICRONEEDLING FOR SKIN REJUVENATION
(LAXITY AND WRINKLES)
Clinical and histologic assessments were done in
10 patients who underwent 6 microneedling treat-
ments using a Dermaroller and the results
showed significant improvement in wrinkles,
skin texture, and overall satisfaction as well as
increased collagen and tropoelastin in biopsy
specimens.19
Statistically significant improvement in the signs
of photoaging (wrinkles, laxity, and texture) was
also seen in another study using a motorized
microneedling device.20
 Microneedling Options for Skin Rejuvenation
Radiofrequency Microneedling
The technology
Not all RFMN devices are equal. There are 2
different types of needle used in these devices:
noninsulated microneedles delivering energy
throughout the needle length, and insulated micro-
needles delivering energy only at the needle tip in
the dermis, thus protecting the epidermis from
heat and thermal damage.
Most devices deliver bipolar RF energy where
the current is traveling between positive and nega-
tive electrodes on the tip, limiting the current in the
treated area for a controlled distribution. With
monopolar RF, the current is traveling between
the active electrode tip in the treated area and a
grounding electrode at a distant body location,
allowing deeper or improved energy penetra-
tion.21,22 Compared with monopolar RF, bipolar
RF requires less energy and provides less energy
depth penetration because of the smaller and con-
tained area of current passage.2
Some radiofrequency microneedling devices on
the market
 INTRAcel (Jeisys, South Korea) device offers
both monopolar and bipolar options. The tip
is composed of 49 insulated microneedles
with 4 needle depth options: 0.5 mm,
0.8 mm, 1.5 mm, and 2.0 mm.
 Fractora (InMode, Israel) has multiple alterna-
tives for tips with different densities, lengths,
and insulation options that function through
bipolar technology: deep dermal, low-
density, 3000-mm, 24-pin tip; deep and sub-
dermal low-density, 3000-mm silicon coated
24-pin tip; and mid-dermal, high-density,
600-mm, 60-pin tip. Morpheus8 is the newest
RFMN device, with deeper needle depths
that spare the dermis for action in the
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
ZALEA Physician Editors Rating 4 out of 5
Overall Rating 7.9 out of 10
Marketing Claims 7.7
Peer-reviewed Literature 6.6
Consistency of Results 8.6
Comfort Level 8.1
Overall Satisfaction 8.4
These results do not reflect ZALEA’s testing or opinion.
3
subcutaneous adipose tissue, and 24 insu-
lated pins with depths of more than 4000 mm.
 Intensif (Endymed, Caesarea, Israel) was the
first FDA-cleared RFMN device. The needle
tip has 25 noninsulated gold microneedles
with needle depths ranging from 0.5 mm to
5.0 mm, power 0 W to 25 W, and pulse dura-
tion 50 to 200 milliseconds.
 INFINI (Lutronic) delivers bipolar RF energy
with 49 insulated microneedles in the tip.
Depths range from 0.5 mm to 3.5 mm, power
2.5 W to 50 W, and pulse duration 10 to
1000 milliseconds. Genius is Lutronic’s
second-generation RFMN device, with propri-
etary technology that allows more precise
needle and energy delivery through contin-
uous impedance monitoring for optimal
treatment.
 Vivace (Cartessa) offers both insulated and
noninsulated 36-microneedle tips. Depths
range from 0.5 mm to 3.5 mm, power 30 W
to 70 W, and pulse duration 100 to 800 milli-
seconds. The system also delivers LED
(light-emitting diode) light at the same time
with 2 options: blue light for an antibacterial
effect and red light for collagen stimulation.
Table 1 shows a comparison between the devices
based on a compilation of physician surveys inde-
pendently conducted using a fixed survey format
and defined criteria by ZALEA. These results do
not reflect ZALEA’s testing or opinion.
The first use of an RFMN device was studied by
Hantash and colleagues23,24 using a bipolar de-
vice that featured temperature and impedance
transcription, allowing the delivery of energy at a
preselected temperature and depth, respectively.
Histologic evaluation of biopsy specimens showed
areas of collagen denaturation (RF thermal zones)
followed by dermal remodeling through neocolla-
genesis and neoelastogenesis.
INFINI Fractora Intensif
4 out of 5 3 out of 5 3 out of 5
7.5 out of 10 7.2 out of 10 6.3 out of 10
8.3 8.5 7.2
7.7 7 6
8.4 8.8 7.6
5.1 3.5 4.2
7.8 8 6.4
4 Alessa & Bloom
RADIOFREQUENCY MICRONEEDLING FOR
ACNE AND ACNE SCARS
Most of literature on RFMN to treat acne scarring
was in patients with dark skin types, given the
increased safety profile and lower risk for postin-
flammatory hyperpigmentation (PIH) with such
treatments.
In 2 of the studies that investigated the efficacy
and safety of RFMN for acne scars in subjects with
skin types III to V, the assessments were done us-
ing the Goodman and Barron’s Global Qualitative
Acne Scarring System (1, macular; 2, mild; 3, mod-
erate; 4, severe). One had 31 subjects with mixed
types of acne scars and these patients had 4 treat-
ments separated 6 weeks apart, using the INFINI
device. Three months after the last treatment
was the final evaluation of results. In the 14 sub-
jects with a baseline of grade 4, 12 (85.71%)
showed a 2-grade improvement and 2 (14.28%)
showed a 1-grade improvement. Of the remaining
17 subjects with a grade 3 baseline score, 13
(76.47%) showed a 2-grade improvement and 4
(23.52%) showed a 1-grade improvement.25 The
other study had 19 subjects who received 3
monthly treatments with the Intensif device. An
evaluation of the treatments occurred 1 month
following 3 separate treatment sessions. Eleven
Fig. 1. Before and 1 month after 3 INTRAcel treatments for acne scars. (Courtesy of Jeisys Corporation, Seoul, KR;
with permission.)
of 19 patients (57.9%) had at least 1-grade
improvement and, 3 months following the third
session, 9 patients were again evaluated and all
showed at least 1-grade improvement. Nine sub-
jects (47.4%) also showed improvement in facial
dyschromia.26
Encountered side effects of these procedures
included pain, erythema, edema, and PIH, all of
which were transient (Fig. 1).
Further acne-related research, investigating
the improvement in active acne lesions and
acne-related postinflammatory erythema with
RFMN, was performed in darker-skinned pa-
tients. The results of those studies support the
evidence that treatment with RFMN produced
decreased inflammation. The results of 3 INTRA-
cel treatments on 25 subjects with moderate to
severe acne showed a 90.11% decrease in in-
flammatory acne, a 76.46% decrease in nonin-
flammatory acne, and a 36.99% decrease in
sebum excretion.27 The INFINI device was used
in a related study for acne-related postinflamma-
tory erythema in which 25 subjects in the treat-
ment group receiving 2 RFMN treatments were
compared with 27 subjects in the control group
receiving oral or topical therapy. Compared
with the control group, the treatment group
showed statistically significant improvement in
 Microneedling Options for Skin Rejuvenation
the investigators’ global assessment score, as
well in objective assessment of erythema with
both photometric device and digital software.
Histologic studies showed decreased vascu-
larity, inflammation, and inflammatory markers
in the treatment group.28 Side effects reported
were pain, erythema, bleeding, scaling, and
crusting, which all resolved in a few days to
1 week (Fig. 2).
Compared with transepidermal bipolar RF, a
randomized clinical trial of 20 subjects with mild
to moderate acne and acne scars was conducted
and subjects had split face treatment: 1 side with
RFMN and the other side with bipolar RF. After 2
monthly treatments, results showed that RFMN
was more effective in improving acne scars, and
showed a reduction in acne lesions and sebum
excretion.7
The results of an efficacy trial comparing RFMN
with a 1550-nm Er:glass fractionated laser in the
treatment of acne scars showed that both groups
had statistically significant improvement
compared with baseline. Although the laser group
showed superior results, there was no significant
difference between the 2 groups. However, more
side effects were noted in the laser group (pain, er-
ythema, edema, dryness), and other side effects,
such as acne and PIH, were only reported in the
laser group.29
Fig. 2. Before and 1 week after 2 INTRAcel treatments for active acne. (Courtesy of Jeisys Corporation, Seoul, KR;
with permission.)
5
RADIOFREQUENCY MICRONEEDLING FOR
SKIN REJUVENATION (LAXITY AND
WRINKLES)
Another large area of interest in which RFMN is
beginning to play a large role is in the improvement
of skin laxity and texture through skin remodeling
and collagen stimulation.
In a multicenter trial, the midface and lower face
were treated with the Intensif device to assess lift-
ing, tightening, and wrinkle reduction. Forty-nine
subjects (skin types II–IV) received 3 monthly
RFMN treatments on the cheeks, submandibular
area, and the neck. Subject evaluation was done
3 months after the last treatment to assess lower
face lifting and skin tightening. The Global
Aesthetic Improvement Scale (GAIS) was used
and results showed that 100% of subjects had
improvement and 65% had significant improve-
ment. For wrinkle reduction and improvement of
skin texture, the Fitzpatrick Wrinkle and Elastosis
Scale was used and results showed significant
reduction from baseline (the average Fitzpatrick
scores were 3.5  1.66 at 3 months compared
with 5.04  1.22 at baseline).30
In another study, Lyons and colleagues31 inves-
tigated the efficacy of RFMN for the improvement
of wrinkles and skin laxity of the décolletage area.
Twelve subjects received RFMN treatment every
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-
sif device. One month following the last treatment
was the evaluation using both the GAIS and 2.
patient-reported satisfaction. Results showed
that 67% of subjects had at least a 1-point GAIS
improvement and 80% of subjects were at least
slightly satisfied31 (Fig. 3). 3.
A study done in Japan, in which 20 patients
received 1 RFMN treatment to the face, showed
that there was a significant volumetric reduction
and skin tightening of the lower two-thirds of the
face 6 months after the treatment when evaluated 4.
by three-dimensional volumetric assessment.
Ninety-percent of patients were satisfied or very
satisfied with the results.32 Twelve months after
the treatment, 15 of the study subjects were eval- 5.
uated and showed significant volume reduction in
the nasal and perioral area, proving the long-
lasting effect of RFMN.33 6.
When using RFMN for skin rejuvenation, studies
reported a similar side effect profile to RFMN used
for acne scars: transient erythema, edema, and 7.
pain.
Topical anesthesia is usually sufficient to pre-
vent pain associated with the RFMN procedure.
Most studies referenced in this article reported
the use of topical anesthetic cream for 30 to
60 minutes before the procedure,26–33 and 1 8.
study25 used topical anesthesia as well as nerve
blocks.
9.
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