Microneedling radiofrequency with sublative radiofrequency versus microneedling radiofrequency with subcision: A randomized controlled study for scar resurfacing, skin rejuvenation and anti-aging

INTRODUCTION

Aging is beautiful; however, there is no denying the fact that there are some parts of youth that everyone wants to retain or recapture as one gets older. Similarly, scars on the face rarely pose a health risk, but patients constantly present with aesthetic, social, and psychological concerns. Most of these patients desire non-invasive procedures with minimal downtime. Hence, there is a growing need for newer and more effective technologies and procedures with minimal side effects to achieve a more youthful and smooth appearance of the face. Microneedling radiofrequency (RF) is a technique whereby thermal energy is conducted to the dermis via fractional microthermal zones. This energy acts on collagen’s triple helix structure, subsequently breaking the intramolecular bonds, resulting in immediate collagen contracture and subsequent neocollagenesis.^[1] A study by El-Domyati et al shows that RF further decreases elastotic material in the upper dermis and induces reorientation of elastic fibers within the papillary and upper reticular dermis.^[2] Various studies have shown significant rejuvenation after microneedling RF treatment.^[3-5] Microneedling fractional RF has also been clinically efficient in managing acne scars with minimal direct damage to the epidermis.^[6] The depth of the needles can be adjusted from 0.5 mm to 3.5 mm, allowing for targeting different layers of the dermis depending upon the type of scars, and a controlled level of tissue damage can be achieved by adjusting the power level and duration of the energy pulse. Subcision is a conventional method used to mechanically disrupt the fibrotic tissue in the dermis that tethers down scars, using a hypodermic needle. The connective tissue formed during the tissue healing process improves scars and overall facial appearance. Few reports have suggested that subcision with various types of needles or blades is effective for wrinkles, prominent nasolabial folds, and acne scars.^[7] In a study of 40 patients who underwent subcision for acne scars, the improvement in average scar score and difference in the visual analog scale were statistically significant (P = 0.0000001).^[8] Sublative RF is a newer technology that creates a low-density coagulative effect in the epidermis and superficial dermis along with subnecrotic heating in deeper layers of the skin and subcutis. In a Korean study involving 20 patients, microneedling RF was delivered first, followed by sublative RF, which offered a synergistic effect from the epidermis down into the dermis and delivered very good results. Out of all, 70% of the subjects reported marked- and near-total improvement both subjectively and objectively. In addition, all three types of atrophic acne scars improved significantly, with a greater response in the order of rolling, boxcar, and icepick scars.^[9] Although microneedling also stimulates the epidermis, Sublative RF leads to better epidermal regeneration and improvement in skin irregularities.

We undertook this study to compare the efficacy and safety of microneedling RF combined with sublative RF versus microneedling RF combined with subcision for scar resurfacing, skin rejuvenation, and anti-aging.

MATERIALS AND METHODS

Study design

In this prospective study, subjects with scars or signs of aging randomly received either of the two treatments. A number of sessions were decided based on the response, patient satisfaction, and affordability, and a maximum of 3 treatment sessions at 4-week intervals were given. Topical anesthesia (prilocaine [2.5%] and lidocaine [2.5%] for 30 min) was given before microneedling RF and subcision, and regional nerve blocks, depending upon the target area (infraorbital, zygomaticofacial, buccal), were given before sublative RF. Target areas were sterilized with alcohol and betadine before treatment. For microneedling RF, an output of 30 and a depth of 2–3 mm was kept, and subjects received 2–3 lesional passes. For sublative RF, RF1 mode and energy level 3 were kept, and subjects received a 2–3 min treatment on 1 area. Both microneedling RF and sublative RF were done in lifting mode as shown in Figure 1. Post-treatment care consisted of applying a mild topical steroid and antibiotic for 2 days, moisturizer, sunscreen, and Tab Paracetamol if required. Subjects were instructed to avoid excoriating the healing lesions.

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Figure 1:

The innovative lifting mode, as demonstrated, helps in contraction and repositioning the ageing-induced drooping and loosening fat planes in an upward and outward direction in antigravity mode. This is against the direction of droop around the nasolabial and mesomental folds. (a) Normal facial fat planes, (b) redistribution, herniation and atrophy of fat with age, (c) Sublative radiofrequency causing subnecrotic heating, breakdown and repositioning of deeper fat layers. Black markings depict directions of sublative radiofrequency. (d) Volumization and lifting effect achieved after sublative radiofrequency. Yellow color depicts supra-orbital fat. Red color depicts infra-orbital fat. Green color depicts cheek fat.

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RESULTS

A total of 40 patients were enrolled in this study and randomly assigned to treatment group 1 (microneedling RF combined with sublative RF) or treatment group 2 (microneedling RF combined with subcision). Group 1 had 14 females and six males, and Group 2 had 18 females and two males. The age distribution of patients varies from 20 to 60 years [Table 1].

The most common indication to seek treatment was post-acne scars (n = 23/40), followed by aging (n = 13/40). Three patients had both aging and post-acne scars, and 1 had aging and uneven skin tone.

Scar and scar texture scores

On examination, icepick scars were present in 22/40 patients (13 in group 1 and 9 in group 2); box scars in 27/40 patients (16 in group 1 and 11 in group 2), and rolling scars in 7/40 patients (3 in group 1 and 4 in group 2).

While both treatment groups noted an overall decrease in scar scores from baseline, as given in Figure 2, group 2 had superior results, which were statistically significant (P = 0.034).

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Figure 2:

Comparison of each treatment group’s baseline and final overall scar scores. While both treatment groups noted a general reduction in scar scores from baseline, Group 2 had superior results compared to Group 1, which were statistically significant.

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Overall, grade B (Moderately atrophic dish-like, punched out small scars with shallow bases but atrophic areas <5 mm) and grade C (Punched out with deep but normal bases, punched out with deep abnormal bases, linear or troughed dermal scarring, deep and broad atrophic areas) scar scores showed a decrease from baseline. In contrast, grade A (Macular erythematous, pigmented, mildly atrophic dish-like) scar scores increased from baseline. None of the patients in the study had hyperplastic papular (grade D) scars or hyperplastic keloidal or hypertrophic (grade E) scars. Figure 3 shows baseline and final mean scar scores for each grade in both groups.

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Figure 3:

Comparison of each treatment group’s baseline and final Grade A-C scar scores. None of the patients had Grade D or E scars. Overall, grade B (Moderately atrophic dish-like, punched out small scars with shallow bases but atrophic areas <5 mm) and grade C (Punched out with deep but normal bases, punched out with deep abnormal bases, linear or troughed dermal scarring, deep and broad atrophic areas) scar scores showed decrease from baseline. In contrast, grade A (macular erythematous, pigmented, mildly atrophic dish-like) scar scores increased from baseline. Y Axis: Score.

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Aging scores

Aging scores reported improvement in all areas except hollowness of temples, hollowness of eyes, and eye wrinkles in group 1 and nasolabial wrinkles and jowl wrinkles in group 2. Both groups reported overall improvement in aging scores as shown in Figure 4, which was more in treatment group 1 compared to treatment group 2, but the results were not statistically significant.

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Figure 4:

Comparison of each treatment group’s baseline and final overall aging scores. Both groups reported overall improvement in aging score, as shown in the figure, which was more in treatment group 1 compared to treatment group 2, but the results were not statistically significant.

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Group 1 had better results in forehead wrinkle score, temple wrinkle score, malar drooping score, the hollowness of eyes score, nasolabial drooping score, jowl drooping score, and jowl wrinkle score; equal results of both groups were seen in forehead drooping score, and group 2 had better results in temple drooping score, malar wrinkle score, puffiness of eyes score and eyes wrinkle score, though none of the individual area scores in one group was significantly better than the other. Baseline and final drooping and wrinkle scores of each of the seven anatomical areas in each treatment group are shown in Figures 5 and 6.

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Figure 5:

Comparison of baseline and final drooping score of each of the seven anatomical areas in each treatment group.

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Figure 6:

Comparison of baseline and final wrinkle score of each of the seven anatomical areas in each treatment group.

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Patient satisfaction scores

Both treatment groups reported mean patient satisfaction scores above Grade 3 (i.e., >75% improvement). Group 1 had a mean patient satisfaction score of 3.05 ± 0.39, while group 2 had a mean patient satisfaction score of 3.15 ± 0.59, but the difference was not statistically significant. Figures 7a and b show clinical improvement in scars and aging in a patient of microneedling RF combined with the sublative RF group. Figures 8a and b show clinical improvement in scars in a patient of microneedling RF combined with the subcision group.

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Figure 7:

(a) Baseline photo of a 26-year-old male with signs of aging, including forehead wrinkles, temporal hollowness, prominent nasojugal groove, nasolabial folds, and post-acne scars. (b) Improvement in overall scar score (from 16 to 9) and overall aging score (from 16 to 11) leading to around 5-year age reversal after three sessions of microneedling radiofrequency (RF) combined with sublative RF. There is a reduced nasojugal groove and nasolabial fold due to a shift in the fat plane and breakage of fibrotic bands, along with collagen building.

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Figure 8:

(a) Baseline photo of a 25-year-old female with acne and post-acne scars with minimal early signs of aging, (b) Improvement in overall scar score (from 6 to 3) and overall aging score (from 6 to 4) after two sessions of microneedling radiofrequency combined with subcision.

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DISCUSSION

The impact of aging on facial appearance can be significant, due to the stressful lifestyle, more so in this pandemic and growing environmental changes, underscoring the need for effective treatments. The emotional toll of acne scars can be substantial, highlighting the importance of addressing both physical and psychological aspects. They vary in color and thickness and have multiple morphologies- ice pick, rolling, or boxcar- and thus often require a combination of different approaches to achieve an optimal cosmetic outcome. Our study leverages the collagen-stimulating effects of microneedling RF to achieve skin rejuvenation and scar improvement via its ability to stimulate neocollagenesis.

This noninvasive technology offers the advantages of reduced downtime and lack of interaction with melanin. Hence, it is safer for skin of color and has a low side-effect profile. This study was conducted to compare the efficacy and safety of the combination of microneedling RF with subcision, a conventional mechanical treatment used in acne scars, versus sublative RF, a newer technology that leads to subnecrotic heating in deeper layers of dermis and subcutis and can be utilized to break fibrotic bands beneath acne scars.

Forty patients participated in this randomized controlled trial, of whom 32 were females, possibly due to more concerns about facial appearance compared to males. Most patients received 1–2 sessions (Mean 1.55 ± 0.60) in microneedling RF combined with sublative RF (Group 1) and 2-3 sessions (Mean 2.55 ± 0.51) in microneedling RF combined with subcision (Group 2). This shows that combining with sublative RF leads to faster results, with patients achieving desired satisfaction with 1–2 sessions.

While both treatment groups noted an overall decrease in scar scores from baseline, Group 2 had superior results compared to Group 1, which were statistically significant. Subcision releases the fibrotic bands of deep “bound-down” scars, and microneedling RF simultaneously creates a milieu of collagen and elastotic breakdown, overall leading to excellent results in scar textures. The synergistic effect of sublative RF with microneedling RF likely contributes to the observed improvements in scar texture and skin laxity. A significantly higher number of sessions in Group 2 could explain the superior results.

Overall, grade B and C scar scores showed a decrease from baseline, while grade A scar scores increased from baseline. Collagen remodeling and subsequent neocollagenesis fill up the deep atrophic dish-like, punched-out grade B and C scars, converting them to milder grade A scars. The improvement was seen in all forms of boxcar, rolling, and icepick scars. Overall skin texture improved in terms of skin smoothness, open pores, and complexion, which led to high patient satisfaction in both groups.

Both groups reported overall improvement in aging score, which was more in treatment group 1 despite a lesser number of sessions compared to treatment group 2, but the results were not statistically significant. Microneedling RF’s action on collagen stimulation leads to coagulation and subsequent formation of collagen bands, causing improvement in wrinkles and skin laxity. Sublative RF, especially when performed in lifting anti-gravity mode as documented in Figure 1, additionally targets and breaks down the drooped-down fat planes and repositions them tightly with renewed strength of dermal collagen bands and traversing bands in fat planes. This leads to improvement in the sagging of facial folds and enhanced facial appearance. A small sample size with more patients in the younger age group (n = 27/40 in 21–40 years vs. n = 13/40 in the 41–60 years age group) having low baseline aging scores and a lesser number of sessions in Group 1 could be the attributive factors for not showing statistically significant difference in antiaging. Larger prospective studies involving subjects with actual or perceptible age >30 years should be undertaken to assess the anti-aging effect of sublative RF. Group 1 had clinically better results in malar drooping score, nasolabial drooping scores, and jowl drooping score due to the easy targeting of these areas in lifting mode with this modality. We noted better results and higher patient satisfaction in patients aged >30 years who had higher baseline global drooping and wrinkle scores, especially. The most common side effects were pain during the procedure, which was more in group 1, and post-procedure erythema and edema, which were transient.

Both treatment groups reported mean patient satisfaction scores above Grade 3 (i.e., >75% improvement). Microneedling RF is an excellent modality to target acne scars and aging skin and achieves good patient satisfaction. Combination with subcision enhances the effect on scars, especially deep adhered scars. Combined with sublative RF, it achieves additional benefits such as improving the sagging of facial folds by repositioning fat planes. Most patients require 1–2 sessions of sublative RF, and results are better in older patients with high baseline global drooping and wrinkle scores.

CONCLUSION

Microneedling RF is a safe, tolerable, and effective modality for acne scars and facial rejuvenation. It can be combined with Subcision for severe atrophic dish-like and punched-out deep tethered scars and may require multiple sessions. Sublative RF is a newer technology that causes diffuse subnecrotic heating of the dermis, breaks fibrotic bands, and leads to the breakdown and repositioning of fat planes when used in innovative lifting mode. It will improve skin texture, skin laxity, and sagging in 1–2 sessions. A combination of this modality should be preferred in patients with scars and actual or perceptible age >30 years and with higher baseline global drooping and wrinkle scores.