Journal of Cosmetics, Dermatological Sciences and Applications, 2013, 3, 110-116
http://dx.doi.org/10.4236/jcdsa.2013.31016 Published Online March 2013 (http://www.scirp.org/journal/jcdsa)
Objective Assessment of Skin Tightening Using
Multisource, Phase-Controlled Radiofrequency in Asians*
Yohei Tanaka1,2,3
1Clinica Tanaka Plastic, Reconstructive Surgery and Anti-Aging Center, Matsumoto, Japan; 2Department of Dermatology, Tokyo
Women’s Medical University, Tokyo, Japan; 3Department of Applied Life Sciences, Niigata University of Pharmacy and Applied
Life Sciences, Niigata, Japan.
Received December 18th, 2012; revised January 20th, 2013; accepted January 28th, 2013
ABSTRACT
Background: Radiofrequency has been proven to penetrate deeper than optical light sources independent of skin color
allowing a safer treatment for the Asian skin type. Many studies have indicated the efficacy of various types of devices,
but have not included a sufficient objective evaluation. Multisource radiofrequency uses multiple phase controlled ra-
diofrequency generators with real time impedance control, allowing painless, deeper dermal heating with better adapta-
tion to differences in individual skin impedance. In this study we used three-dimensional imaging for the objective
evaluation of facial skin tightening by multisource phase-controlled radiofrequency. Methods: Twenty Japanese
patients were treated with a multisource phase-controlled radiofrequency device. Three-dimensional imaging was
performed with a Canfield Scientific Vectra camera and software, and quantitative volume measurements were taken to
evaluate the change in the post-treatment volume. The patients then provided subjective assessments. Results: Ob-
jective assessments of the treated cheek volume evaluated by a three-dimensional color schematic representation with
quantitative volume measurements showed significant improvement three months after the final treatment. The mean
volume reduction at the last post-treatment visit was 3.878 ± 2.86 mL. The post-treatment volume was significantly
reduced compared to the pretreatment volume in all of the volunteers (P = 0.0007). Ninety-five percent of volunteers
reported satisfaction with the improvement of skin laxity, and ninety percent of volunteers reported satisfaction with the
improvement of wrinkles, such as the nasolabial folds. Conclusions: The advantages of these multisource phase-con-
trolled radiofrequency treatments are its high efficacy for skin tightening associated with minimal level of discomfort,
minimal side effects, and low cost. Taken together, these characteristics facilitate the ability to give repeated treat-
ments as a stand alone treatment or adjunct to surgery. This study provides for the first time a qualitative and
quantitative volumetric assessment, proving the ability of the technology to reduce the volume through non inva-
sive skin tightening.
Keywords: Objective Evaluation; Quantitative Volume Measurement; Skin Laxity; Three-Dimensional Imaging;
Wrinkles
1. Introduction
Demand for a non-invasive and long-lasting treatment to
reduce wrinkles and laxity has grown dramatically over
the past few decades as new aesthetic technologies have
been introduced into practice. A major cause of wrinkles,
laxity and cellulite is the reduction in the quantity and
quality of collagen in the dermis and hypodermis [1].
We previously reported that near-infrared can pene-
trate deep into human tissue, achieve skin tightening [2-
4] and muscle thinning [5,6], and non-thermally induce
various responses in the skin and subcutaneous tissues
[7-12].
Radiofrequency (RF) devices have also been widely
used for skin tightening and are thought to heat the der-
mis and subcutaneous tissues, thereby stimulating dermal
collagen remodeling. It is well documented that one of
the effects of dermal heating is an immediate change in
collagen structure, followed by a long-term stimulation
of neocollagenesis starting at 4-6 weeks after treatment
[13]. These thermal effects can help reduce the appear-
ance of wrinkles and laxity and improve contours on both
the face and body.
*Financial disclosure statement: I did the work without receiving any
financial support from any third party. I have no relevant financial
activities outside the submitted work.
Disclosure: None of the authors of this study have a conflict of interest.
The thermal effects of monopolar and bipolar RF have
been proven to be beneficial in skin tightening. Never-

Objective Assessment of Skin Tightening Using Multisource, Phase-Controlled Radiofrequency in Asians 111
theless, these effects are often partial or unpredictable
because of the uncontrolled nature and possible pain pro-
duced during monopolar or unipolar RF treatments and
the superficial nature of energy flow for bipolar or tripo-
lar configurations. In addition these first-generation RF
therapy systems delivered frequently unpredictable re-
sults, possibly due to the large differences in individual
skin impedance [14].
In our clinic, a novel multisource phase-controlled sys-
tem is used. In Multisource RF systems, first introduced
in 2009, six independent RF generators produce the RF.
Each of this generators is phase controlled, allowing a
complex 3 dimensional interaction between the electro-
magnetic fields produced in the tissue. Since adjacent
electrodes, on each side of the handpiece, posses iden-
tical polarities, no current is created between these elec-
trodes on the skin’s surface and most of the energy is
driven deeper into the skin with minimal epidermal flow
(Figures 1 and 2).
In addition to the new RF delivery technology, the tested
system allows for continuous real-time measurement of
skin impedance and delivers constant energy to the pa-
tient skin independent of changes in its impedance. Se-
veral studies have shown the efficacy of multisource RF
in both skin tightening and fractional RF skin resurfacing
but these studies did not include an objective evaluation
of the post treatment volumetric tissue changes [1,14-17].
Conventional evaluations using photographs have been
widely used, but they do not provide an accurate objec-
tive assessment. Therefore, in this study, a 3-dimensional
(3D) photographic system was used to evaluate the amount
of post-treatment volume change.
The aim was to quantifiably assess and provide defini-
tive clinical evidence of skin tightening using multisource
phase-controlled RF treatment not only subjectively, but
also objectively.
2. Materials and Methods
2.1. Japanese Volunteers
Twenty Japanese volunteers (18 females and 2 males)
aged 26 to 69 years (mean age, 42.4 ± 9.92 years) with
Figure 1. Configuration of six phase controlled RF sources
as implemented in the Endymed Pro multisource techno-
logy. Multisource RF technology is based on the fact that
flow of energy on the surface is minimal, while all energy is
directed to the depth of the tissue. This is achieved by re-
pulsion between electrical field of the same polarity on each
side of the handpiece.
Figure 2. Qualitative electromagnetic field simulation of the tissue effects of simple biolpar RF (left) and mutiple phase
controlled RF generators (right). Since the multisource RF handpiece delivers energy in constant circulatory motion the
effect will be an average lower temperature on the epidermis (<43 deg) and higher temperature in the lower skin layers,
without the need for cooling. This technology allows the system to keep epidermal temperature bellow 43 deg while reaching
up to 57 deg in the depth of the tissue.

Objective Assessment of Skin Tightening Using Multisource, Phase-Controlled Radiofrequency in Asians 112
Fitzpatrick skin type 3 to 5 were enrolled in this study.
The volunteers did not have a history of any type of
skin disease or cosmetic procedure affecting the treat-
ment areas within the last 3 years. Volunteers did not
have any specific diet. No volunteers exhibited weight
loss during the study periods. No topical pre-treatment
medication was used, and the post-treatment skin care
regimen consisted of a gentle cleanser and sunblock. All
volunteers gave written informed consent for participa-
tion in the study after reading the experimental protocol
and being advised about the risks of treatments.
2.2. RF Treatment
The RF device used in this study was the FDA cleared,
EndyMed PRO™, (Endymed Medical, Cesarea, Israel).
This system uses multiple phase-controlled RF genera-
tors, emitting RF at 1 MHz frequency, 1 to 65 watts.
Twenty Japanese volunteers were treated on both cheeks.
Three treatment sessions with a 1-week interval between
treatments were performed.
Volunteers were treated at a 33 W output, which al-
lowed a painless procedure. If the volunteer reported a
strong sensation of heat, the handpiece was rotated slightly
faster and/or the treatment head was moved slightly away
from the point of heat sensation. No topical anesthetics
or oral analgesics were administered before, during, or
after the treatment. In addition, no skin cooling was re-
quired.
2.3. Objective Assessments
Digital photographs and 3D imaging with quantitative
volume measurements were conducted as objective as-
sessments with a Canfield Scientific Vectra camera and
software (Canfield Scientific Inc., Fairfield, New Jersey).
This system is designed to accurately capture the surface
shape and also 2D color information of the human body.
The capture sequence of Vectra was set to less than 3 ms
in order to capture the shape accurately even if the sub-
ject was not perfectly still.
A 3D color schematic representation indicates the
volume changes between pretreatment and post-treatment
images in the face, and shows the varying degrees of
tightening achieved in colors ranging from yellow to red.
Green areas indicated no changes to the face.
In this study, volume change was observed as volume
reduction in the cheek, and recorded in milliliters. Care
was taken to ensure similar non-smiling facial tone in
both pretreatment and post-treatment photographs.
2.4. Subjective Volunteer Assessments
Subjective volunteer assessments were performed using
questionnaires in which the volunteers were asked to
give their degree of satisfaction in terms of skin laxity
and wrinkles based on a 5-point scale ranging from 0 to 4
(0 = worse; 1 = little satisfaction or not satisfied; 2 =
fairly satisfied; 3 = satisfied; and 4 = very satisfied).
Questionnaires were given 3 months after the final treat-
ment.
2.5. Statistical Analyses
The differences were examined for statistical significance
using the Wilcoxon signed rank test. A P < 0.05 was set
as a cut-off for statistical significance. Data are repre-
sented as means ± standard deviation (SD).
3. Results
Objective assessments evaluated by 3D color schematic
representation with quantitative volume measurements show-
ed significant improvement after the treatment (Figures
3-5).
The mean volume reduction measured at the last post-
treatment visit was 3.878 ± 2.86 mL. The post-treatment
volume significantly reduce compared with pretreatment
volume (P = 0.0007). Ninety-five percent of volunteers
reported satisfaction with the improvement of skin laxity,
and ninety percent of volunteers reported satisfaction
with the improvement of wrinkles, such as the nasolabial
folds (Figure 6).
Subjective volunteer assessments were performed us-
ing questionnaires (below). The volunteers were asked to
give their degree of satisfaction in terms of skin laxity,
Figure 3. Representative photographs of tightening effects
treated with a multisource phase-controlled RF treatment.
Pretreatment (Above, left), a 44-year-old Japanese woman
exhibited skin laxity in cheek, mental portion, and neck,
and wrinkles such as nasolabial fold. Post-treatment (Above,
right), significant improvements were noted in both skin
laxity and wrinkles. Three-dimensional color schematic re-
presentation shows the varying degrees of tightening achieved
in colors yellow to red (Below). Green areas remain un-
changed. These images indicate significant improvement
of appearance, skin laxity, and wrinkles after the treat-
ments.

Objective Assessment of Skin Tightening Using Multisource, Phase-Controlled Radiofrequency in Asians 113
Figure 4. Representative photographs of tightening effects
treated with the RF device. Pretreatment (Above, left), a 50-
year-old Japanese woman exhibited skin laxity in cheek,
mental portion, and neck, and nasolabial fold. Post-treat-
ment (Above, right), significant improvements were noted
in both skin laxity and wrinkles. Three-dimensional color
schematic representation shows significant improvement of
appearance, skin laxity, and wrinkles after the treatments.
Figure 5. Representative photographs of tightening effects
treated with the RF device. Pretreatment (Above, left), a 69-
year-old Japanese woman exhibited skin laxity in cheek,
mental portion, neck, and nasolabial fold. Post-treatment
(Above, right), significant improvements were noted in both
skin laxity and wrinkles. Three-dimensional color schematic
representation shows significant improvement of appear-
ance, skin laxity, and wrinkles after the treatments.
and wrinkles. Subjective volunteer assessments are shown
as follows: very satisfied (blue), satisfied (light blue),
fairly satisfied (green), and not satisfied (red). Question-
naires were given 3 months after the final treatment. Ninety-
five percent, and 90% of volunteers were satisfied with
the improvements in skin laxity, and wrinkles, respec-
tively.
The mean degrees of satisfaction in terms of skin lax-
ity and wrinkles based on a 5-point scale from 0 to 4
were 3.45 ± 0.887 and 3.15 ± 1.040, respectively. There
was a very good correlation between the volume reduc-
tion in the cheeks and patient satisfaction.
Volunteers did not report pain during the RF treatment,
even though it was performed without anaesthesia and
Figure 6. The volume reduction measured by compared the
volume at their first pretreatment visit and the last post-
treatment visit. The post-treatment volume was signifi-
cantly reduced compared with pretreatment volume in all
the volunteers (P = 0.0007) (above). Data represent the
means ± SD. Significant differences are indicated (*: P <
0.05).
contact cooling. Side effects, such as epidermal burns,
adipose tissue atrophy, and contraction, were not observed,
and the volunteers felt comfortable throughout the study.
4. Discussion
Regardless of skin type, skin laxity is one of the most
common complaints among aging patients. Although in-
vasive or ablative procedures, such as face-lifts or laser
resurfacing, are affective in skin tightening, the down-
time and potential adverse effects are not well accepted
[18]. Noninvasive skin tightening procedures can be par-
ticularly applicable to skin of color, such as Asians, be-
cause such procedures are skin-type independent [18].
Furthermore, the aging process of the skin of Asians dif-
fers from that of Caucasians, with mid-face aging, such
as sagging of the malar fat pads, being a common mani-
festation [19]. Therefore, skin tightening is an important
aspect in the management of skin aging in patients of
color [18].
Whereas nonablative intense pulse light skin rejuvena-
tion heats up the superficial dermis, deep tissue heating
that involves radiofrequency or near-infrared sources
aims to induce thermal injury in the deep tissue [20].
The aim of deep tissue heating is to stimulate new col-
lagen formation, which can achieve skin tightening. Due
to its better tissue penetration, RF treatment is capable of
volumetric heating of the mid to deep dermis as well as
selective heating of the fibrous septa strands and fascia

Objective Assessment of Skin Tightening Using Multisource, Phase-Controlled Radiofrequency in Asians 114
layer [21]. Specifically, RF energy heats hydrodermal
collagen, promoting both collagen remodeling and skin
tightening [22]. Clinically, these effects promote dermal
and hypodermal collagen production and the tightening
of these deep subcutaneous structures [15,21]. RF de-
vices have been used in thermal delivery systems to pro-
vide the beneficial effects of heat while avoiding some of
the downfalls of more standard lasers [23].
RF has been shown to penetrate deeper than optical
light sources independent of skin color, and is beneficial
for skin tightening. We previously described the tighten-
ing effects of near-infrared objectively and histologically,
and reported that near-infrared can penetrate deep into
human tissue to achieve skin tightening [2-4] and muscle
thinning [5,6], as well as non-thermally induce various
responses in the skin and subcutaneous tissues [7-12].
In this study, we evaluated the efficacy of multisource
phase-controlled RF treatment both subjectively and ob-
jectively.
One of the major issues in all skin tightening clinical
studies is the lack of an accepted standard regarding the
accurate assessment of the degree of skin tightening [18].
Many studies have suggested efficacy of various types of
aesthetic devices, but these studies have not included a
sufficient objective evaluation. Conventional evaluations
using photographs have been widely used, but do not
provide accurate objective assessment. In this study, a
3D photographic system was used to evaluate the amount
of post-treatment volume change quantitatively. A 3D
imaging approach with quantitative volume measure-
ments (Canfield Scientific Vectra camera and software
system) is an effective visual communication tool for
skin tightening. Standardized lighting and optically
guided object positioning are essential for appropriate
pre- and post-treatment evaluation. Photographs are ta-
ken from two directions and a 3D quantitative analysis is
systemically performed. Thus, 3D quantitative analysis
can evaluate and present the effectiveness and duration
of the results objectively as well as show patients results
that are not demonstrable with standard, 2D photography.
Although the volume measurement was performed
three months after the final treatment, the post-treatment
volume was significantly reduced compared to the pre-
treatment volume in all of the volunteers. Since the ef-
fects of this RF treatment are clinically observed for at
least several months after the treatment, further studies of
volume measurements with a longer follow-up time are
needed. Most of the volunteers were satisfied with the
improvements in skin laxity and wrinkles, even though
the results of the volume measurements were not signifi-
cant in some volunteers.
Monopolar RF is the first nonablative RF technology
shown to be effective for skin tightening [24,25]. The
original monopolar RF protocols, using single-pass, high
fluence regimen, were associated with a greater degree of
discomfort and complications, including tissue irregula-
rity and burns [24]. A multipass, low fluence regimen has
been developed with the aim of reducing the discomfort
of patients and the risk of adverse effects. Avoiding in-
advertent overlap of volumetric areas and the use of
lower energies with multiple passes may improve effi-
cacy and minimize the risk of unintended thermal injury
[26]. However, the low predictability of monopolar RF
treatments and the discomfort that is associated with this
procedure is still substantial despite the use of low flu-
ence and multiple passes. Finally, because the device has
a disposable tip that can only be used for a single treat-
ment session, the cost effectiveness of this procedure is
another important concern.
In bipolar RF one generator is connected to two elec-
trodes on the surface of the skin. In this case the energy
delivery will be usually superficial following the shortest
way between the electrodes. Other systems with single
source of RF connected to 3 or more electrodes (tripolar,
multipolar) will provide results similar to bipolar. Both
first generation monopolar and bipolar systems are asso-
ciated with low predictability of treatment results possi-
bly due to large variation of skin impedance causing
large variation in the energy delivered into the skin lay-
ers.
In this study, a novel multisource phase-controlled
system was used, which allows for enhanced energy
penetration to lower dermis and hypodermis minimizing
epidermal heating. To enhance predictability of energy
delivery the system employs a continuous real-time mea-
surement of skin impedance allowing delivery of con-
stant energy to the patient skin independent of changes in
its impedance. A 33 W output was used. Treating each
10 cm × 10 cm skin area for 30 seconds allows a painless
procedure without the need for cooling or anaesthesia. A
significant improvement was observed after three rounds
of treatment at this output. Each round of treatment con-
sists of six passes. However, more rounds of treatments
or a higher output may enhance the effects. Only a few
volunteers were unsatisfied with their individual results,
and were mainly patients with thicker skin. Therefore,
additional rounds of treatment or a higher output may be
needed for these patients.
Side effects, such as epidermal burns, adipose tissue
atrophy, and contraction, were not observed, and the
volunteers felt comfortable throughout the study. Further
studies are necessary to determine if a higher output,
increased frequency of treatments, or longer periods of
treatment may be even more effective in skin tightening.
It should be noted that this was a preliminary study
based on a fairly small number of volunteers. We cannot
exclude the possibility that intrinstic and extrinstic fac-
tors in everyday life may affect the changes demon-

Objective Assessment of Skin Tightening Using Multisource, Phase-Controlled Radiofrequency in Asians 115
strated in this study. Therefore further studies in this area
are warranted in a larger numbers of patients and with
longer post-treatment periods to evaluate variations in
treatment parameters and correlations with patients’ en-
vironmental factors.
5. Conclusions
This study examined of first time in Asian population the
volumetric changes and subjective effects after treatment
with multisource radiofrequency. We found significant
improvements in skin laxity through 3 dimensional ob-
jective assessments of facial volume. The statistically
significant volume reduction measured in treated areas, 3
months after the end of treatment sessions proves a long-
lasting skin tightening effect probably to collagen re-
modeling. Efficacy of the treatment was associated with
high predictability of the results with remarkably high
subjective patient satisfaction rate.
In our view, this study highlights the advantage multi-
source RF treatment for higher efficacy, reduced dis-
comfort as well as low cost non invasive skin tightening.
Our data show that phase-controlled, multisource RF ir-
radiation provides safe and effective treatment of facial
skin laxity and for wrinkle reduction in Asian patients.
6. Acknowledgements
I thank Dr. Yoram Harth (O. R. Medical Center) for pre-
cise data and the file for Figures 1 and 2; Mr. Yohei
Nagaoka for three-dimensional imaging performed by a
Canfield Scientific Vectra camera and software; and the
members of J. Hewitt for helpful comments about Endy-
Med PRO™, a phase-controlled, multisource RF system.
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