class="t m0 x0 ha y47 ff3 fs7 fc0 sc0 ls1 ws0">tant collagen remodeling [6-8].
In the past several years, several fractional RF systems
have been introduced that allow controlled fractional skin
resurfacing, similar to the results achieved with various
laser systems. In addition to the epidermal effect, frac-
tional RF systems allow enhancement of the dermal layer
thus contributing to a combined effect leading to an ef-
fective micro-ablative skin resurfacing and improved ap-
pearance of wrinkles, fine lines and acne scars.
The novel TriFractional approach using the new Tri-
Fractional applicator from Pollogen® is designed to en-
able fractional skin resurfacing and treatment of wrinkles
via controlled epidermal micro-ablation and concomitant
dermal remodeling with a long established, highly reli-
able, and cost-effective technology. Treatment with the
new TriFractional applicator can be also done as part of a
combination procedure, the TriLipo MED procedure,
custom tailored to the patient, using additional technolo-
gies, TriLipo RF and TriLipo DMA, incorporated in the
same device, the multi-application Maximus system.
The current research was intended to evaluate the safe-
ty and effectiveness of the novel TriFractional technol-
ogy and applicator for skin resurfacing and treatment of
wrinkles.
2. Methods
2.1. TriFractional Technology
The TriFractional applicator is indicated for skin resur-
facing and the treatment of wrinkles by means of mi-
cro-ablation and coagulation. The TriFractional applica-
tor is one of the modules on the Maximus system. A dis-
posable treatment tip, containing a matrix of bi-polar elec-
trode pins, is attached to the distal end of the applicator
and is placed on the skin for treatment. TriFractional RF
energy is delivered to the skin in a fractional manner via
an array of multi-electrode pins.
Radiofrequency current is delivered sequentially be-
tween each of the pin electrodes and the large electrode
which surrounds the pin matrix. Due to this design, rela-
tively high RF current densities are formed in the tissue
under each pin electrode, resulting in localized fractional
treatment micro-wounds in the epidermis which are in
direct contact with the electrodes while heat is delivered
deeper into the dermis. This fractional manner of energy
delivery leaves intact zones in between the targeted areas
which serve as a reservoir of healthy cells to promote
faster, more effective wound healing.
The TriFractional technology emits a “train” of three
fractional sub-pulses spaced by very short pauses of
Thermal Relaxation Time (TRT), in one treatment pulse.
This modality enables to achieve an enhanced effect of
deeper penetration and optimized efficacy, with less dis-
comfort to the patient and a deeper gradual thermal ef-
fect.
Shortly after treatment there is moderate skin erythema
and edema in the treated zone, which resolves within 1 -
3 days.
During the healing phase, small pin-point epidermal
crusts appear at each micro-ablated spot. These crusts
exfoliate naturally after a few days leading to mild epi-
dermal resurfacing. In the dermis, treatment induces re-
modeling of dermal collagen (neocollagenesis) and of
other matrix molecules, leading to dermal renewal.
2.2. Clinical Methods
A clinical evaluation was conducted treating healthy vol-
unteers in order to assess the safety and efficacy of the
TriFractional technology. The subjects were treated for
various aesthetic reasons such as treatment of wrinkles,
acne scars and un-even skin complexion.
The protocol included 2 or more (according to treated
skin condition) treatments with the TriFractional appli-
cator at four weeks interval.
In addition, selected subjects were treated using the
TriLipo Med procedure which includes:
Week 1: TriFractional
Week 3: TriLipo focused RF + DMA
Week 5: TriFractional
Week 7: TriLipo focused RF + DMA
The addition of the TriLipo technology which com-
bines TriLipo focused RF and DMA resulted in enhanced
improvement of skin texture, toning and tightening. The
TriLipo RF thermal effect stimulates collagen production
while DMA is essential in improving lymphatic drainage
and reducing edema.
Prior to treatment a medical history was taken to ex-
clude any contraindication such as pregnancy, any im-
plantable electronic device that could be disrupted by RF
energy and any active dermatological or collagen-vascu-
lar disorder. Patients signed an informed consent form.
Topical anesthesia (Emla, AstraZeneca) was used on
some of the subjects prior to the treatment according to
the manufacturer instructions. The decision whether or
not to use an anesthetic on treatment area was made by
the physician based on size or sensitivity of the treatment
area, treatment parameters and the subject’s reported
general tolerance.
The face was thoroughly cleaned and the treatment
was performed only after the skin was completely dry.
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One treatment of the TriFractional applicator with a
high power pulse (150 msec) was performed.
Subjects were provided with a “patient-controlled manual
switch” which enabled them to stop the treatment should
they experience significant discomfort. The TriFractional
treatment parameters for each subject were defined ac-
cording to the area being treated and the severity of the
condition. During the first visit, the first few pulses were
of low power level, in order to assess the immediate re-
sults. Once the initial skin response was assessed the
physician decided on the power level according to sub-
ject’s skin condition.
Subjects were asked to provide feedback regarding the
pain level during treatment and were also questioned
about the recovery process following each TriFractional
treatment. Typically erythema and edema appeared and
lasted for 1 - 3 days. A fractional eschar (matrix) pattern
typically appeared 1 to 2 days post treatment and lasted 3
days to one week, depending on the skin characteristics
and treatment strength. Subjects were instructed to use
sun screen continuously to avoid risk of pigmentary
changes.
2.3. Histology
To demonstrate the TriFractional effect on epidermal and
dermal skin layers, preliminary tests were performed on
porcine skin followed by comprehensive in-vivo and ex-
vivo histological examinations.
2.3.1. Porcine Skin
Fresh porcine abdomen and ear skin samples were ex-
posed to different TriFractional energy levels.
2.3.2. In-Vivo Human Abdominal Skin
One abdominal patient consented to a series of TriFrac-
tional pulses prior to her scheduled mini abdominoplasty.
Pulses of the High power default settings (160 msec)
were performed at one week and one day before the sur-
gery. Skin samples of treated and untreated control area
were taken from this patient during her abdominoplasty
procedure for histological analysis. Formalin fixed, par-
affin embedded sections were prepared and stained with
H&E for pathological examination by Patho-Lab Diag-
nostics Ltd., Nes Ziona, Israel. Pathological examination
was performed by Andrea Gat, M.D., Head of Dermato-
pathology Unit, Sourasky Medical Center, Tel Aviv, Is-
rael.
2.3.3. Ex-Vivo Human Skin Study
The Gredeco ex vivo skin model for maintaining skin frag-
ments (harvested from donors undergoing plastic surgery)
in survival condition and artificially aging by Ultraviolet
(UV) irradiation, was used as previously described by
Boisnic and Branchet [7].
Histological modifications of the skin were analyzed
at different intervals between Day 0 (D0) and Day 10
(D10), using H&E staining.
Immunohistochemical analysis of mitotic index of the
epidermis was done on D2. An antibody Ki67 (Dako,
clone MIB-1, marker cells in the M, S, G1, G2 phases
of the cell cycle) was used. The immunodetection was
made with an indirect technique of immunoperoxy-
dase in 4 levels, amplified (kit DAKO) and stained in
red by AEC (3-amino-9-ethylcarbazole).
The results were expressed in % of positive epithelial
cells.
Morphometrical analysis of collagen fibers was done
at D10.
Serial sections of 4 µm thickness were obtained and
specifically stained with a picric acid solution containing
0.1% Sirius red. Collagen was analyzed by computerized
morphometrical analysis. For a quantitative analysis of
these macromolecules, a computerized image analysis of
each section was made. The stained slides were exam-
ined using a microscope (Leitz) (magnification ×160)
connected with a camera unit (XC-75 CE type) and a
microprocessor (Q520).
The surface of collagen bundles were measured in µm2
and the relative collagen content of the dermis was then
expressed as a percentage.
For both the analyses of epidermal mitotic index and
quantitative collagen content, samples with more than
one pulse on the same area were included to amplify the
reaction comparing to control samples.
2.3.4. Statistical Analysis
The statistical significance of changes recorded was de-
termined using the Student’s t-test when p < 0.05 was
considered as statistically significant.
3. Results
3.1. TriFractional Facial Treatments Results
The results of the TriFractional treatments included re-
duction of fine wrinkles, improved appearance of acne
scars, a general improvement of skin texture and scar tis-
sue, skin brightening, skin tightening, improvement of
skin irregularities and reduction in pore size. The sub-
jects treated with the TriLipo Med procedure displayed
an additional facial contouring effect especially visible
on the jaw-line area.
No significant undesired effects were experienced by
the subjects and they reported a tolerable pain level. All
subjects expressed satisfaction with the clinical results.
Figures 1 - 3 demonstrate results of TriFractional treat-
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120
treatment.
ments. Figure 1 shows impressive peri-oral wrinkles im-
provement after two TriFractional treatments. Figure 3 demonstrates impressive improvement of se-
vere acne scars following TriFractional treatments.
Figure 2 demonstrates results following one TriFrac-
tional treatment for improvement of skin non-homoge-
nous complexion post chemical peel, causing perioral hy-
popigmentation. Results demonstrated a substantial im-
provement after only one TriFractional treatment with a
short recovery time. One week post treatment there were
no scabs or other residual signs of the TriFractional
3.2. TriLipo MED Procedure Results
Figures 4 - 6 demonstrate the effect of the TriLipo MED
procedure for improvement of wrinkles and scars and for
general facial contouring.
Figure 1. Peri-oral wrinkles improvement. Before (left) and after two TriFractional treatments (right).
Figure 2. Skin revitalization. Before (left), after one week post one TriFractional treatment (right).
Figure 3. Treatment of acne scars. Baseline, multiple acne scars with uneven skin (left), 2 weeks post one TriFractional treat-
ment (middle), 2 weeks post 3 TriFractional treatments (right).
Treatment of Wrinkles and Acne Scars Using the TriFractional, a Novel Fractional Radiofrequency
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121
Figure 4. TriLipo MED Procedureacne scars and skin texture improvement. Before (left) and after (right).
Figure 5. TriLipo MED Procedure showing the improvement of wrinkles and skin tightening. Before (left) and after (right).
The subjects underwent treatments with the TriFrac-
tional applicator on selected problematic areas, and addi-
tional complementary treatments with the TriLipo RF
and DMA applicator on the entire face. Results indicate a
significant facial contouring in lower cheeks and jaw line
as well as improvement of wrinkles and acne scars. These
results clearly demonstrate the additive value of the uni-
que TriLipo MED procedure, combining TriFractional,
TriLipo RF and TriLipo DMA technologies for facial skin
rejuvenation and facial contouring.
3.3. Histological Results
3.3.1. Porcine Skin Histologies for Preliminary
Evaluation
In all treated porcine skin samples there is thermal injury
in the epidermis alone or up to and including the upper
dermis, depending on the treatment parameters and thick-
ness of skin fragment. The epidermal changes are char-
acterized by elongation of nuclei, and by epidermal ne-
crosis to various extents. The dermal changes are char-
acterized by condensation in the dermal connective tis-
sue.
Depth of injury is in direct correlation to the energy
level used. In samples from abdomen skin treated with
low power, epidermal injury was the least prominent and
only the basal lower spinous epidermis layer was invol-
ved and the dermis was spared. The epidermal changes in
this series were focal with skip area of normal epidermis
in between the involved foci. All the other series showed
both epidermal and dermal injury correlated with the le-
vel of energy in terms of depth and width.
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Figure 6. TriLipo MED Procedure showing skin tightening
and improvement of lips appearance. Before (left) and after
(right).
The ear skin samples are significantly more sensitive
compared to abdomen skin samples, and even at low en-
ergy levels, there are areas of significant damage.
The histological results of the effect of varying power
levels on the porcine skin emphasize the importance of
careful selection of the treatment parameters. Figures 7
and 8 demonstrate the histological findings immediately
following TriFractional treatment.
3.3.2. In Vivo Human Abdominal Skin
Samples taken one day after treatment showed epidermal
necrosis in the involved area and an affect on the papil-
lary as well as upper reticular dermal collagen areas.
Skip areas are visible between affected areas. Neutro-
philic infiltrate was present (Figure 9).
Samples taken 1 week after treatment show intact (re-
generated) epidermis in foci covered with scale crust
(sign of previous damage). Dermal collagen affected areas
are demonstrated. Minimal lymphocytic infiltrate was
present (Figure 10).
3.3.3. Ex-Vivo Human Skin Study
Histologies show epidermal modifications with a modi-
fied or necrotic appearance within 3 quarters of the epi-
dermis or within all of the epidermis. In other cases, lim-
ited destruction of the epidermis was found with second-
dary elimination of the necrosis shaped zone appearing
as a squamous crust. In even rarer cases, alterations were
very moderate, with condensed or vacuous spaces ob-
served in the cytoplasm of the keratinocytes.
From D3 to D10 partial reparation was observed with
the elimination of the crust (parakeratosis zone and ne-
crotic debris), and regeneration of the basal cell layer
under the modified epithelial zone (Figure 11).
3.3.4. Evaluation of Mitotic Index of Epidermis
The immunodetection realized just adjacent to the RF
Figure 7. Porcine abdomen skin fragment treated with low
energy (H&E stain, ×200). Normal skin “with a skip area”
between 2 electrodes (left). Epidermal thermal effect under
electrode. Elongation of epidermal nuclei mainly in basal
layer and lower spinous layer. No thermal effect observed
in dermis (right).
Figure 8. Porcine abdomen skin fragment treated with rela-
tively high energy (H&E stain, ×100). Epidermis: areas of
thermal damage with elongated epidermal nuclei at both si-
des (area under electrodes). In between at ~0.5 mm width,
effect is moderate. At bottom of skip area elongated nuclei
are seen due to penetrated heat dispersion effect. Conden-
sation of upper dermis is seen. Depth of injury ~0.5 mm.
treatment zones using antibody Ki67 revealed a statisti-
cally significant augmentation of positive epithelial cells
(Figure 12). The percent of these mitotic cells rose from
an average of 3.07% ± 1.57% in experimentally aged
skin to 8.9% ± 3.03% in the skin treated by TriFractional
RF (p = 0.0017). This represents an increase of nearly 3
times the amount of positive epithelial cells between ex-
perimentally aged skin and experimentally aged skin treated
by fractional RF.
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123
Figure 9. In-vivo abdominal skin histology 1 day after treat-
ment (H&E stain, ×200). Epidermal damage covered by
crust, dermal effect and neutrophilic infiltrate are demon-
strated.
Figure 10. In-vivo abdominal skin histology 1 week after
treatment (H&E stain, ×200). The epidermis is regenerated
and covered with scale crust, dermal effect and lymphocytic
infiltrate are demonstrated.
Figure 11. Ex-vivo UV aged skin histology at D3 (up) and D10 (bottom) in survival medium (H&E stain magnification ×400: 1
cm = 19 µm). Left: untreated. Right: treated with TriFractional RF pulse. D3 treated sample demonstrate epidermal scarring
with the formation of a new epidermis while old epidermis is eliminating. Condensation of upper dermal collagen fibers is
observed. D10 treated samples demonstrate moderate alteration of the epidermis and dermis.
Treatment of Wrinkles and Acne Scars Using the TriFractional, a Novel Fractional Radiofrequency
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124
Figure 12. Ex-vivo UV aged skin histology at D2 in survival medium. Immunohistochemical analysis of mitotic cells in the epi-
dermis (Ki67, ×400: 1 cm = 19 µm). Left: untreated. Right: treated with TriFractional RF pulse. Increase of mitotic cells in
the zone adjacent to the fractional RF treatment area is demonstrated.
3.3.5. Histological Quantification of Dermal Collagen
by Computerized Image Analysis
Morphometry of collagen revealed a statistically signifi-
cant augmentation from 62.7% ± 1.75% average collagen
for experimentally aged skin to 72.5% ± 4.07% collagen
for skin treated by fractional RF (p = 0.00019). This cor-
responds to 15.5% increase of collagen content (Figure
13).
4. Discussion and Conclusions
During the past years, the fractional treatment concept
became trendy as it offers a controlled skin treatment of
specific tiny areas with enhanced healing through the
surrounding untreated areas. Extensive attempts have
been made to investigate the clinical and histopathology-
cal effects of fractional energy sources on dermal and
epidermal structures.
Several fractional RF systems have recently been clear-
ed for marketing based on published clinical results with
these RF fractional systems [9-11].
Hruza et al. [9] evaluated the effect of a fractional RF
applicator (Matrix RF by Syneron) for skin rejuvena-
tion and wrinkle reduction. Their histological findings,
immediately post-treatment, revealed demarcated zones
of ablation/coagulation/necrosis and subnecrosis up to a
depth of 450 micron. Higher energy levels generated
deeper effects. Subjects undergoing facial treatment had
minimal pain, no permanent side effects, or significant
downtime. The investigators’ assessment of improvement
in skin texture was greater than 40% for approximately
50% of subjects. Higher energy levels and lower cover-
age rates produced better aesthetic results along with less
pain. They concluded that RF fractional skin resurfacing
results in a safe, tolerable and effective improvement in
skin texture and reduction of wrinkles. The depth of tis-
sue ablation, coagulation and necrosis and the relative
proportions of these phenomena were found to be con-
trollable and could be modulated to optimize treatment of
variable dermatologic conditions.
Another study [10] further evaluating the effect of the
eMatrix system by Syneron, confirmed that the treat-
ment improved skin appearance while addressing some
of the limitations of ablative resurfacing and non ablative
skin rejuvenation. Authors reported that unlike fractional
ablative laser treatments, which mostly affect the epider-
mis, the sublative technique has less impact on the epi-
dermis and most of the effect is in the dermis. They con-
cluded that healing is rapid and downtime is minimal
thus treatment is appropriate for all skin types and is an
effective alternative for patients with darker skin.
The current study demonstrates the safety and efficacy
of the novel fractional RF technology, the TriFractional.
The evaluation provides clinical and histological evidence
supporting the TriFractional being a promising technol-
ogy for skin rejuvenation, treatment of wrinkles and acne
scars and for general improvement of skin texture, with
minimal down time and minimal discomfort to the pa-
tient. Histological results confirmed the TriFractional im-
pact on epidermal renewal and dermal regeneration and
demonstrated the biological mechanism of the effect. Im-
mediate effect as well as effect following a few days was
demonstrated in various histological models, while ex-
vivo results support the in - viv o findings. Combining the
TriFractional treatment with intermediate TriLipo RF and
TriLipo DMA using the TriLipo MED Procedure, en-
hances facial toning and enables a holistic approach to
facial rejuvenation and enhancement.
In summary, the fractional mode of the treatment en-
ables a faster, more effective healing process, eliminating
patient downtime resulting in a safe, tolerable, effective
skin rejuvenation.
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Treatment of Wrinkles and Acne Scars Using the TriFractional, a Novel Fractional Radiofrequency
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Figure 13. Ex-vivo UV aged skin histology at D10 in survival medium. Histological analysis of dermal collagen stained by
sirius red (×400: 1 cm = 19 µm). Left: untreated. Right: treated with TriFractional RF pulse. Increase of collagen fibers in the
dermis under the fractional RF treatment zone is demonstrated.
5. Disclosures
Dr. Levenberg acts as a medical director for Pollogen.
The other authors received from Pollogen research grants
for the corresponding study projects.
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