Radiofrequency treatments...


...for anti-ageing, skin tightening (face/body) and cellulite removal

High intensity, deep tissue radiofrequency is widely accepted to be the strongest body skin tightening treatment known today and arguably the best facial skin tightening technology and cellulite reduction technology too. Radiofrequency is also an amazing anti-ageing treatment that not only firms the skin but also boosts circulation and is proven to stimulate collagen and elastin production, for firmer, more elastic skin and overall skin rejuvenation.

As our specialisation at the LipoTherapeia clinic is facial skin tightening and body skin tightening/cellulite, we have worked for more than seven years with radiofrequency. In order to know exactly what I am talking about and to offer the best to my clients, I have also intensively studied the Physics of radiofrequency in detail, reviewed all the research and assessed/tried hands-on most important machines. Having studied Physics at university in the past was quite useful for that.

On this page I would like to share some of my knowledge with you, so in the next several weeks I will be adding more and more articles about radiofrequency, especially technical information to help you decide what is the best radiofrequency treatment for yourself as a client or for your clinic as a practitioner.

However, for legal and practical reasons and for the sake of neutrality, I will not be able to suggest / provide information about a specific machine, treatment or clinic, neither reply to emails with specific technical queries about radiofrequency. Such emails will not be answered.

I hope this page will prove helpful to you. If you are happy with what you read, please feel free to share this page on your blog/website/social media.

Georgios Tzenichristos|  LipoTherapeia, London



Please also note that this guide is based on my research and clinical experience on this subject, but it is not guaranteed to be totally accurate or impartial and contains my own personal views as a practitioner on radiofrequency and the best way to apply it. Of course, this guide is not aimed to diagnose/treat any medical condition or replace medical treatment or advice.



All articles on this page: © 2017 Georgios Tzenichristos & LipoTherapeia Ltd

What is radiofrequency & how it works



What is radiofrequency treatment?

Radiofrequency treatments have been used for more than five decades in physiotherapy and for two decades in aesthetic treatments. Radiofrequency treatments refer to high frequency electrical currents, 300kHz-40MHz.

Applied on the body or face at a lower frequency, electrical currents may produce muscle contraction or other effects. At "radio" frequencies, electrical currents produce just heat.

Depending on the machine you have, the protocols you apply and even the skin products you use (cream, gel etc), heat can be very superficial (e.g. focusing on epidermis for acne treatment), very deep (e.g. focusing in joints or muscles for physiotherapy) or anywhere in between. For aesthetic treatments, radiofrequency is focused on epidermis (acne, superficial skin tightening, skin rejuvenation); dermis (medium depth skin tightening, lifting, skin rejuvenation); subdermis (deep skin tightening, lifting, cellulite); or subcutaneous tissue (spot fat reduction).



Radiofrequency diathermy

When heat is deep we are talking about radiofrequency diathermy or true radiofrequency. As applying heat on the epidermis can be achieved by all sorts of other means, including infrared, laser, hot water and even a hot pack, there is not much point in providing superficial radiofrequency per se, except in the case of acne.

The idea of RF is to mainly affect the deep tissues (dermis, subdermis, subcutaneous fat), while largely bypassing the epidermis. Affecting mainly the epidermis, while leaving the deeper tissues largely unaffected, is pointless, because as a result such treatment will burn the epidermis before the dermis or subdermis experience any therapeutic levels of heat.



Most RF treatments focus so much on the epidermis, they are not true radiofrequency

Unfortunately, however, this is what many radiofrequency machines provide: very superficial heating - hence all these burning/scarring cases you see on places websites with radiofrequency. True radiofrequency should not cause superficial burning. If it does, it's pointless. If for whatever reason you want to burn/ablate your skin (e.g. for deep peeling) there are CO2 lasers for that. True radiofrequency should leave the epidermis alone and focus deep in the skin - that was the reason why it was first invented. I will discuss this issue in more detail in other parts of this guide.



Where does the name derive from? Does RF have anything to do with radiation, radioactivity or microwaves?

As radio communications happen to be of the same frequencies as those used for these treatments, they have been named radiofrequency treatments. However, there is nothing else common between radio communications/radiation/radioactivity and radiofrequency treatments. Radio communications/radiation/microwaves/radioactivity refer to electromagnetic waves, while radiofrequency treatments involve high frequency electricity - and in some cases a high frequency electromagnetic field - and that's it. Definitely no radiation, microwaves or radioactivity at all.



How does radiofrequency treatment work

As we discussed above, radiofrequency is a smart way to provide deep heating to tissues, without burning or irritating the epidermis in the process. According to research, intense heating on deep tissues has quite a few benefits: it boosts collagen and elastin production and blood circulation, for increased tightening and elasticity and overall skin rejuvenation. When applied quite deeply, it also stimulates fat release from fat cells, leading to spot far reduction and cellulite removal. And when applied a bit more superficially it also helps tighten pores and inhibit the action of sebaceous glands, leading to a clearer complexion with less acne or enlarged pores.



The exact mechanism

With radiofrequency treatment, electrical current enters the skin from one pole, which is charged positively, and then exits the skin from another, which is charged negatively. A split of a second later, the polarity changes and what used to be a plus pole becomes minus and vice versa. This happens hundreds of thousands or millions of times a second.

Now if the frequency of the current was much lower, for example 100Hz (one hundred such polarity alternations per second) then we would have muscular contraction. Indeed such low frequencies are used in TENS machines for pain relief and in other physiotherapy machines for muscle rehabilitation etc.

As we mentioned earlier, at higher frequencies we do not have muscular contractions, we just have heat. This is because the frequency is so high that so called "motor nerves" are not fast enough to sense the polarity alternation, so no muscular contraction occurs.



Molecular movement = heat

Now the question is: how is heat being produced with radiofrequency?

The answer is simple. if you remember from high school Physics, heat is random molecular movement. With RF currents, the alternation of the current is so fast that no charge or no molecules ever really move towards one pole or the other. As a result, molecules just vibrate around a central position or simply rotate. This random molecular movement (vibration or rotation) manifests macroscopically as heat.

In a nutshell, this is how radiofrequency works: it vibrates our molecules, producing heat.

Monopolar or bipolar RF machine?



What is best for skin tightening?

A very common question I am asked is what is the difference between unipolar, monopolar, bipolar and multipolar (i.e. tripolar, tetrapolar, octipolar) radiofrequency? Which one is best for skin tightening?

First of all, let's make it clear: there are only two poles in electricity: plus and minus. That's basic Physics from high school. So all these names (tripolar, tetrapolar, octipolar whatever-polar) are a misnomer and a little bit of a gimmick, especially when it comes to eight poles, which is an overkill and unnecessary (more on that later). Let me first explain what is monopolar and bipolar, and then I will move to multipolar and unipolar.

But to answer the question on the title of this paragraph, let me just say that for both deep and superficial skin tightening, monopolar radiofrequency wins hands down.



What is monopolar radiofrequency?

In monopolar RF the (+) and (-) poles are located quite far apart from each other. As a result, the current has no other choice but to traverse through ALL skin layers after entering the skin, travel through the body to the other pole, and exit there.

This means that with monopolar RF, and depending on some other factors too, we can treat not only the skin surface (epidermis) but also the middle skin layer (dermis), the deepest skin layer (hypodermis/subdermis) and even the subcutaneous fat deposits below the skin itself.

As I mentioned above, how deep we treat depends on some other factors too, not just on bipolar/monopolar arrangement. However, in most setups monopolar RF allows us the opportunity to go quite deep. Unfortunately this is not the case with bipolar RF, which is restricted to quite superficial treatment, no matter what gimmicks are used to make the current "go deeper".

This is the reason that we do not use bipolar/multipolar RF at our clinic, even though our machine provides that option. We don't even use bipolar RF for superficial treatment, e.g for acne, as we can fine-tune our monopolar machine to work superficially in a much better way than bipolar can ever do.



What is bipolar radiofrequency?

With bipolar radiofrequency the plus (+) and minus (-) poles are located very close to each other - too close for deep treatment.

Because the poles are close to each other (in most machines they are almost adjacent to each other), the current has no other choice but to briefly and superficially penetrate the skin (as little as one millimetre (i.e. the maximum depth of epidermis) and then exit the skin again from the other pole, not very far from where it entered. Quite often the "trajectory" of the current spans just the epidermis.

This means that if we want to properly treat the dermis (and even more so if we want to treat the hypodermis or subcutaneous fat), we must first literally burn the epidermis, which is in the way and absorbs almost all of the current. Because nobody would even want to burn the epidermis, treatment intensity is adjusted at lower levels. This keeps the epidermis happy but deeper skin layers are not treated properly.

Epidermal heating gives the impression of a very strong treatment, with lots of redness and quite often irritation, and there is some superficial tightening. However, not much collagen/elastin production is stimulated in the dermis/subdermis below and definitely no cellulite fat or deep fat reduction (which is located even deeper) ever occurs.

If intensity is increased, in order to work on deeper skin layers and produce some skin firming/lifting, the epidermis is burned/irritated and/or severe pain is experienced, hence some of these burn pictures and extreme pain stories in review websites.

Indeed there are gimmicks such as numbing creams, surface cooling and vacuum suction, to provide deeper treatment with bipolar RF. However, none of those really work well and they also have their own problems: numbing creams cover the intense pain and increase the likelihood of tissue injury/burning; there really is no point providing superficial cooling to avoid excess superficial heat, as the two negate each other and the whole exercise is just a waste of energy; and vacuum suction causes skin stretching/loosening, thread/spider veins and in addition does not allow for the use of active ingredients, which if used can enhance the skin tightening effects of radiofrequency.

In a few words, bipolar RF is just too superficial. Period.



Tripolar, tetrapolar, octipolar and other multipolar radiofrequency

As I mentioned earlier, there are only two poles in electricity. So how come there exists a tripolar radiofrequency machine?

The answer is simple: with tripolar radiofrequency, there are three electrodes, with the two poles (the plus and the minus), always alternating between the three electrodes. At any given time one of them is a minus, the other is a plus and the other is inactive.

With tetrapolar RF, the two poles alternate between four electrodes, with two being inactive at any given time. With octipolar it is two active and six inactive. And so forth...

In theory, this alternation of poles results to more uniform and/or deeper heating. In practice, all you would need to produce deeper heating would be to move just two pole apart - you don't need all this multipolar gimmick. And in any case, you would still not go as deep as with monopolar. With regard to heating uniformity now, this is also pointless. With almost all RF treatments the therapist continuously moves the handpiece, which provides plenty of uniformity without the need of all those "poles".

All in all, I find multiple poles a marketing gimmick. Of course the manufacturers of these machines would disagree. But Physics is Physics. Monopolar means going through all skin layers, while bipolar/multipolar means staying largely on the surface. In nature, electrical current, or any other energy potential differential, will choose the shortest possible distance to travel. Simple.



Unipolar radiofrequency

Unipolar RF is also another form of bipolar. With bipolar RF the two poles are located next to each other, as in left and right. With unipolar RF one pole is in the centre, while the other pole is around the first pole (this is called a coaxial arrangement).

Whatever I said about bipolar and multipolar RF applies to unipolar too: it is too superficial. The current will seek the shortest possible distance to travel through the skin, and as the poles are so close to each other, no matter what gimmick is employed, the current will travel superficially. 



Machines with monopolar and bipolar options

Luckily, the better machines on the market offer two or more choices: monopolar or bipolar (or any of the varieties, mentioned above). If you are a practitioner and bought one of those machines, my advice is to just use monopolar. Focus on it, train on it and use it well, and it will be much better than any bipolar arrangement, even if you wish to offer very superficial treatment.

If you are a client, I would definitely advise you to go for monopolar. Some bipolar machines may work well for some applications, but in three words, "monopolar is king".



If monopolar is so much better, why do bipolar machines exist?

The reason is simple: cost. Monopolar machines need to employ higher intensities, as they heat the skin deeply. This means bulk, heavy weight, almost no portability and cost. You can't find a good monopolar machine for less than £20,000.

On the other hand, you can make a pretty cheap, small, light and portable bipolar machine which is also called "radiofrequency" machine for as little as £700, while useless "home use" bipolar machines can cost as little as £200. Since the public does not know the difference and thinks all radiofrequency machines do the same thing, you get the main idea behind bipolar machines.

Due to just superficial heating, even a cheap bipolar machine, may in some cases appear to be very hot and powerful and impress the client, while in reality it is not so powerful at all, and does not treat the deeper skin layers. Obviously, you should not expect much in the way of results from those, either for your clients, as practitioner, or for yourself, as a client.



How do I know what kind of RF treatment I am receiving?

The answer is very simple. If a metal or self adhesive pad is used to connect you to the machine, then you are having a monopolar RF treatment. If your only contact with the machine is the operator handpiece, then you are having a bipolar-type treatment.



Deep/superficial RF treatment: important, but not the whole picture

Of course, depth of treatment is not the only important thing in radiofrequency, neither it is only affected by the arrangement of poles, and these are subjects that we I am discussing in other parts of this guide.

Resistive or capacitive RF treatment?



Which is the best for cellulite and skin tightening?

We have already discussed one variation of radiofrequency treatments, i.e. monopolar vs bipolar RF. On this page we will be discussing two other aspects of the technology: capacitive versus resistive radiofrequency treatments. This aspect is not as well known as bipolar vs monopolar, but it is equally important if you wish to choose correctly the best RF radiofrequency machine for your clients/patients or the best radiofrequency treatment for yourself.



What is resistive radiofrequency?

When the radiofrequency handpiece that gets in contact with the body is made of stainless steel, and thereby allows electricity to pass through to the skin relatively unimpeded, then we are talking about resistive radiofrequency. This is because in this case the surface of the skin (epidermis) acts as a resistor.

As the skin has quite low impedance/resistance , the surface of the skin does not get too hot, allowing RF to work deeper, especially if we use monopolar RF. So resistive RF and monopolar RF both result in deeper treatment.



What is capacitive radiofrequency?

When the radiofrequency handpiece that gets in contact with the body is made of ceramic, plastic or other material that does not conduct electricity, and thereby necessitates electricity to "jump" through the skin, then we are talking about capacitive radiofrequency. This is because in this case epidermis, as well as the ceramic/plastic material on the handpiece, act as capacitors.

In this case, heat develops in the interface between skin and handpiece, so treatment is unavoidably more superficial, and the epidermis gets very hot. This means that capacitive RF treatment is more superficial, especially when a bipolar/unipolar/multipolar arrangement is used. So capacitive and bipolar RF both result in more superficial treatment.



Deep vs superficial RF

Nothing wrong with superficial/epidermal treatment, but it's a bit of a waste. You do not need a multi-thousand pound machine to heat the epidermis: you can do that with an infrared lamp, hot pack, sauna or even hot water, at a much lower cost. However, it pays to remember that radiofrequency was developed in order to helps us provide deep treatment.

On the other hand capacitive RF is a valuable addition to a system that also provides a resistive option, but only in a monopolar RF system. This allows the operator to switch between deep, medium or superficial treatment, according to the needs of the client. A handful of quality machines offer both a capacitive and a resistive option to offer full flexibility to the operator.



How do I know what kind of RF treatment I am receiving?

The answer is very simple. If the handpiece makes contact with your skin via a stainless steel tip, then you are having resistive treatment. if the tip is made of ceramic or plastic, then treatment is capacitive.

The issue between capacitive vs resistive is of less importance than the issue between bipolar and monopolar. IMHO, monopolar is far superior to bipolar, while a good therapist may do a good job with either a capacitive or resistive machine.