*The first question most surgeons will ask is, does RFAL and heat really work to enhance soft tissue contraction?*

Internally applied RF energy also travels preferentially up and down the vertical FSN, especially with RFAL, as the current is already flowing vertically from the deep electrode to superficial electrode direction, parallel to the vertical FSN. These concepts were outlined in a number plastic surgery, peer reviewed articles [13–15]. The FSN acts as the conduit for low impedance transport of radiofrequency energy from the internal electrode up to the external electrode. The vertical fibrous septa comprise the vertical encasing septa of the adipose tissue and thus the casing around the adipose tissue is more selectively and rapidly heated by the vertical FSN.

*Internal and External Radiofrequency Assisted Lipo-Coagulation (RFAL) in the Control of Soft… DOI: http://dx.doi.org/10.5772/intechopen.97378*

The FSN acts as the conduit for RF conduction and experience a higher concentration of the RF power density and result in more efficient vertical contraction. *It is the vertical, oblique and even horizontal contraction of the FSN that leads to most of the thermal contraction effects of the soft tissue* [4]*.* This contraction of the FSN, in the vertical, oblique and horizontal vectors *lead to a 3-dimensional contraction in the X, Y and Z axis.* The bipolar-contained energy in the RFAL configuration leads to more efficient bulk heating of soft tissue with no dissipation of heat below the electrode. Dissipation of RF energy and mono-probe RF systems such as ThermiRF and the diffuse radiant heat of laser, although effective and provide heating and certainly when end points are achieved result in tightening, are less efficient than the RFAL bipolar patented configuration of InMode RF.

There is a large body of evidence in peer-reviewed articles that shows the highly efficient nature of the RFAL contraction experience [13–15]. An article published in 2011 in Esthetic Plastic Surgery, using perfused abdominoplasty specimens and the RFAL bipolar electrode applicators to heat the internal soft tissue to various temperatures [15].

The various named horizontal fascia fibers throughout the soft tissue such as camper's and Scarpa's fascia in the abdomen need to be heated to approximately 61.5 degrees Celsius to exhibit contraction and the contraction is in the order of 14%. *This is certainly substantial contraction, but it turns out that the vertical, oblique and horizontal fibrous septa, the vertical, oblique and horizontal FSN, when heated to 69.4 degrees Celsius resulted in an on-the-Table 33% 3-dimensional contraction. And 60–70% contraction measured overtime and with superficial thermal RFAL treatment as well* [10–15]. This paper was the first to point out that internal thermal stimulation to a temperature of 70 degrees can result in immediate contractions in the range of 33% [2]. Using even smaller internal electrode FaceTite applicators in the order of 1.2 mm, contractions of up to 43% -50% have been reported.

#### **4.1 The role of RFAL in superficial skin tightening and dermal remodeling**

RFAL also works on tightening the superficial soft tissue and dermis. In fact, in many areas of the body and in many patients, there may not be much subcutaneous fat, which means less FSN. In other patients, there is lots of fat and FSN, but the soft tissue is very loose (tummy, inner thigh and upper arm) and the clinician must tighten the deeper adipose tissue and FSN as well as the superficial fat layers and provide safe and effective dermal heating to optimize "best in class" contraction. Technologies, such as Plasma (Renuvion), Vaser Ultrasound (Sound Surgical), Laser (Cynosure) cannot provide a safe subdermal and superficial subcutaneous thermal control and become dangerous in these body areas. When it comes to the jawline, face, upper and lower lid, the AccuTite and FaceTite are unparalleled for subdermal skin tightening and *"best in class"* thermal contraction and cosmetic outcomes. Add to the list, the Morpheus 8, which also comes loaded on your BodyTite or Embrace workstation and no wonder, InMode RFAL technology is by far the *worlds #1 thermal soft tissue contraction system,* as it adds so much certainty to the patient and the physician practice that deploys it.

The external electrode and the RFAL system provide gentle heating through nonablative, sub-necrotic remodeling of collagen. There is biopsy-proven evidence in published papers on the nature of this gentle trans-epidermal heating and sustaining epidermal temperatures to 38 to 42 degrees over a series of treatments can result in increased messenger RNA up regulation of 35%. When between four and eight treatments are provided, increased collagen contents of 8–15% have been demonstrated [7–9]. *Combining the FSN RFAL contraction with superficial subcutaneous and dermal remodeling and, even Morpheus, 60–75% soft tissue contraction can be achieved* [10–15].

When we combine the internal RFAL, vertical, oblique and horizontal *FSN 33–43%* 3-dimensional contraction produced on the table, with the gentle transepidermal, dermal, papillary dermal or reticular **10–25% remodeling**, significant soft tissue, non-excisional, contraction can be achieved with RFAL technology. An excellent published paper that documents accurately the effect of RFAL skin tightening was published by editor of this Intech Open book, Dr. Diane Duncan in the Esthetic Surgery Journal in 2013 [17, 18]. In Dr. Duncan's article she replicated the study performed by Dr. Barry DiBernardo except this time using RFAL bipolar radiofrequency heating technology; the FaceTite and NeckTite and replicating the same clinical protocol (**Figure 3**). India ink tattooed rectangles were made on each side of the lower abdomen. On one side, after tumescent anesthesia, RFAL was performed heating the deep subcutaneous tissue to 69 to 70 degrees with an epidermal end point of only 36–38 degrees Celsius. Following heating to these thermal end points, standard suction-assisted lipoplasty was performed. On the contralateral side, after tumescent anesthesia, standard suction-assisted lipoplasty was performed without RFAL thermal stimulation or coagulation.

Dr. Duncan followed these abdominal-tattooed soft tissue individuals for six months and twelve months. Dr. Duncan's article is the only long-term thermal contraction study in the literature. Many physicians raised the question that perhaps internal thermal stimulation led to short-term contraction, but by one year perhaps there was no appreciable effect and the Dr. Duncan article this was refuted this quite demonstrably. What she found on the SAL non-thermal side was a 14% contraction at six months, which had fallen to 6% at 12 months showing the stress relaxation of the non-thermal aspiration technique. Six percent contraction by subdermal stimulation and stimulation of the viscoelastic fibers in the adipose tissue can be important, especially in those individuals who have inherently good skin tone. For those individuals, however, who have decreased skin tone or elasticity and laxity, 6% contraction at 12 months will not be enough.

On the RFAL side, she found there was a 24% contraction at six months, and this had increased to 35% area contraction at 12 months. This excellent peer-reviewed and randomized, blinded trial using an extremely accurate contraction instrument, the Vectra 3D and proved quite conclusively that RFAL definitely provides long-term contraction. 35% area soft tissue contraction at 12 months is by far the industryleading thermal coagulation system. This long-term contraction of 35% (single level FSN RFAL) can give significant non-excisional tightening to the neck, jawline and face as well as body areas where laxity-post contouring or without fat contouring at all is one of the primary clinical outcomes of the esthetic intervention. *However, what is even more impressive, the 35% area contraction at 12 months in this study, was achieved without superficial subdermal work at skin temperatures of only 36 degrees Celsius. By adding superficial RFAL and subdermal work, together with the Morpheus8 studies have shown 60–70%, 12-month soft tissue contraction is achieved* [10–15].

Additional thermal contraction can be provided by not only superficial and subdermal RFAL, but by the simultaneous use of the Morpheus and/or the Fractora, particularly the silicone-coated applicator, and radiofrequency ablative needling and radiofrequency ablation. Simultaneous Fractora with the 24-pin coated will provide a deep papillary and reticular ablation that can be combined with the ablative and necrotic experiences soft tissue effects of the internal electrode combined with a non-ablative bipolar heating of the FaceTite RFAL external electrode (**Figure 16**). Simultaneous use of the Morpheus 8 or Fractora combined with FaceTite, NeckTite and even BodyTite is outlined in chapter are an additional soft tissue coagulation tightening tool to optimize clinical results [19–21].

*Internal and External Radiofrequency Assisted Lipo-Coagulation (RFAL) in the Control of Soft… DOI: http://dx.doi.org/10.5772/intechopen.97378*

#### **Figure 16.**

*Optimal soft tissue contraction and tightening can be achieved by combining the 35% contraction with RFAL and the Fractora dermal contraction following fractional RF resurfacing being performed immediately after RFAL.*
