- Expert says radiofrequency has potential to evolve to neuromodulator alternative
- With proper technique, RF device can achieve results lasting 12 to 18 months
- Treatment with novel RF device best performed with oral or IV sedation
B otulinum toxin has become a mainstay approach in the treatment of the wrinkles that result from frowning, but some patients may still be hesitant to undergo the neurotoxin treatment. They may be skeptical because of safety issues, or they're not interested in the frequent repeat treatments needed to maintain cosmetic results. Now, a novel treatment using bipolar radiofrequency energy to de-innervate the musculature responsible for the frowning mimic may represent a viable treatment option for these individuals.
The Relaxed Expressions device (BioForm Medical), approved by the Food and Drug Administration, is a radiofrequency-based system that temporarily de-innervates the branches of the frontal nerve and the angular nerve to deactivate the brow depressors. The heat produced by the radiofrequency ultimately weakens and disables these targeted nerves and prevents the musculature that they innervate from fully contracting.
The transcutaneous nerve stimulator (left) being used to identify the branches of the frontal nerve that innervate the corrugator supercilii muscle, and (right) the radiowave probe in place, ready to produce a heat lesion on the nerve.
"This is the first nonsurgical wrinkle-softening alternative to Botox (onabotulinumtoxinA, Allergan) which can safely and effectively address frown lines," says Joe Niamtu III, D.M.D., a cosmetic facial surgeon in Richmond, Va. "In experienced hands, the radiofrequency device can achieve much longer-lasting results, which may range from 12 to 18 months, sparing patients the need to repeat their Botox treatments every three months."
THE PROCEDURE Using an external cutaneous nerve stimulator, the surgeon first identifies the frontal nerve branches at the lateral brow that innervate the corrugator supercilii muscles. There are numerous branches of this nerve that can activate the frontalis and orbicularis as well as the corrugator, and, Dr. Niamtu says, the crux of the procedure is to deactivate the corrugator without affecting the frontalis or orbicularis oculi function.
The nerve stimulator is used to precisely find the branch that will contract the corrugator supercilii without the frontalis or orbicularis. Next, the lateral nasal region is tested with the nerve stimulator to identify the angular nerve which innervates the procerus muscle and the medial head of the corrugator supercilii.
After these two nerves are identified, the skin is marked and a small bleb of local anesthesia is injected inferior to the mark. An 18-gauge needle is then inserted at the bleb and the probe handpiece is inserted and tunneled to the skin marking. Here, the internal nerve stimulator is activated to reconfirm the precise location of the frontal branches and angular nerve. Once these regions are confirmed, the probe is activated and emits radiowaves to produce heat and induce a lesion on the motor nerve.
The machine and handpiece for the Relaxed Expressions device (BioForm Medical). (Photos credit: Joe Niamtu III, D.M.D.)
The goal is to produce three to five lesions along the path of the indicated nerves to ensure their deactivation. The internal nerve stimulation is repeatedly performed and then followed by radiowave lesion induction. Depending on the level of experience, the procedure can take an average of approximately 30 minutes to complete.
"The clinical effect is almost immediate and can be quickly assessed in those patients that are awake enough to follow commands and frown. However, for patients that cannot animate due to sedation, the physician must use the nerve stimulator and experience to determine the treatment endpoint," Dr. Niamtu says.
OPTIONS OTHER THAN BOTOX The mimetic muscles provide the very important function of animation. Humans can communicate many emotions without saying a word, and the role of the brow and forehead muscles are paramount in this ability. However, continual use of the brow depressors produces skin wrinkles in the glabellar region. Dr. Niamtu says that although treating this area with botulinum toxin injections has revolutionized cosmetic medicine and raised this branch of medicine to new and never-before-seen heights, botulinum toxin treatments are not for every patient.
"The advent of neuromodulator treatment provided a true paradigm shift in cosmetic facial surgery in that it provided a safe, reliable and nonsurgical means of mitigating the effects of the brow depressors. Although neuromodulator treatment is the most common cosmetic surgical procedure in the world, surgeons, patients and researchers still search for alternatives to chemodenervation. Radiofrequency is one treatment option that offers a solution for this cosmetic thorn and may placate those patients fearful of more invasive surgery and skeptical of botulinum toxin therapy," Dr. Niamtu explains.
ADVERSE EVENTS Treatment with the novel radiofrequency device may be somewhat uncomfortable and is best performed with oral or IV sedation. Local anesthesia is not used, as it would induce motor paralysis, which would affect the procedure. The most common adverse events associated with the radiofrequency procedure include ecchymosis and edema, but they become less common with increased experience of the physician. According to Dr. Niamtu, under-treatment is manifested by a subtotal paralysis, and over-treatment can result in cutaneous burns or, very rarely, unwanted frontalis or orbicularis oculi paralysis.
"My first patient had a great outcome that lasted about five months. However, other patients had subtotal results or results that were not long-lasting enough to validate the procedure. In retrospect, I believe that the less-than-optimal results had everything to do with my inexperience concerning this new technology. Practice makes perfect, and I believe that radiofrequency has a great potential to evolve into a treatment alternative to neuromodulators, with longer-lasting cosmetic results," Dr. Niamtu says.
DISCLOSURES: DR. NIAMTU REPORTS NO RELEVANT FINANCIAL INTERESTS.