Radiofrequency for the treatment of skin laxity: mith or truth

Araújo, Angélica Rodrigues de; Soares, Viviane Pinheiro Campos; Silva, Fernanda Souza da; Moreira, Tatiane da Silva

doi:10.1590/abd1806-4841.20153605

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Sumário

Review • An. Bras. Dermatol. 90 (5) • Sep-Oct 2015 • https://doi.org/10.1590/abd1806-4841.20153605 linkcopy

Radiofrequency for the treatment of skin laxity: mith or truth^*

Authorship SCIMAGO INSTITUTIONS RANKINGS

The nonablative radiofrequency is a procedure commonly used for the treatment of skin laxity from an increase in tissue temperature. The goal is to induce thermal damage to thus stimulate neocollagenesis in deep layers of the skin and subcutaneous tissue. However, many of these devices haven't been tested and their parameters are still not accepted by the scientific community. Because of this, it is necessary to review the literature regarding the physiological effects and parameters for application of radiofrequency and methodological quality and level of evidence of studies. A literature search was performed in MEDLINE, PEDro, SciELO, PubMed, LILACS and CAPES and experimental studies in humans, which used radiofrequency devices as treatment for facial or body laxity, were selected. The results showed that the main physiological effect is to stimulate collagen synthesis. There was no homogeneity between studies in relation to most of the parameters used and the methodological quality of studies and level of evidence for using radiofrequency are low. This fact complicates the determination of effective parameters for clinical use of this device in the treatment of skin laxity. The analyzed studies suggest that radiofrequency is effective, however the physiological mechanisms and the required parameters are not clear in the literature.

Keywords:
Esthetics; Radio waves; Rejuvenation; Skin aging

	Author/Year	Treated area	Equipment/ manufacturer	Characteristics (Frequency/ power W or energy J / nozzle size/ Temperature)	Application time / N. of sessions / Frequency
1.	Shapiro et al, 2012¹⁶	Face	TriPollar (RF)	1 MHz/ 50 W/ Nozzle: not mentioned / 35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 8 sessions/ once a week.
2.	Abrahan et al, 2004¹⁷	Upper part of the face and neck	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2/ Temperature not measured.	45 to 60 minutes/1 session.
3.	Rusciani et al, 2007¹⁸	Forehead, neck and arm	Dual Frequency/ Ellman Inter-nacional	4 MHz / Power not mentioned / Nozzle: 0.78 cm2/ Temperature not measured.	15 to 20 minutes/ 1 session.
4.	Hsu et al, 2003¹⁹	Upper face, orbital region and eyebrow region, chin, neck,	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2 / Temperature not measured.	Time not mentioned/ 1 session.
5.	Harth et al, 2010¹²	Face	Radiofrequencia Bipolar	1 MHz / 6 W / Nozzle 2 cm2 / Temperature not measured.	Time not mentioned/ 4 sessions/ once a week.
6.	Bassichis et al, 2004²⁰	Upper third of the face	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2/ 35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 1 session.
7.	Lee et al, 201¹⁶	Face	Matrix RF Bipolar	1 MHz / 25 J/ Nozzle 1.4 cm2 / Temperature not measured.	Time not mentioned/ 3 sessions/ every 2 weeks.
8.	El-Domyati et al, 2011²¹	Face	Biorad. Shenzhen GSD Tech Co	6 MHz / 150 J and 200 J/ Nozzle 3 cm2 / Temperature not measured.	Time not mentioned/ 6 sessions/ every 2 weeks.
9.	Javate et al, 2011²²	Periorbital wrinkles and midface laxity.	Pelleve' SkinTightening System	4 MHz / Power not mentioned / Nozzle 1 cm2/ Temperature not measured.	35 minutes / 8 sessions / once a week.
10.	Friedman et al, 2007²³	Face	Accent. AlmaLasers Ltd	40.68 MHz / 60 to 140 W/ Nozzle 2 cm2 / 39 to 44 ° C in the epidermis	15 to 30 minutes/2 to 6 sessions/ every 15 days.
11.	Fitzpatrick et al, 2003²⁴	Face	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2 /35 ° C to 45 ° C in the epidermis.	Time not mentioned/1 session.
12.	Alster et al, 2004²⁵	Cheek and neck	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2/35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 1 session.
13.	Carruthers and Carru-thers. 2007²⁶	Face	ThermaCool/ Thermage.	6 MHz / 330 W / Nozzle 1 cm2/35 ° C to 45 ° C in the epidermis.	30 minutes to 2h20 minutes/ 6 sessions/ once a month.
14.	Finzi and Spangler. 2005²⁷	Face and neck	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2/35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 1 session.
15.	Kushikata et al, 2005²⁸	Nasolabial folds, marionette lines and cheeks	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2//35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 1 session.
16.	Levenberg. 2010²⁹	Abdomen, thighs, face, buttocks and arms	Apollo radiofrequency system. Pollogen	1 MHz/ 50 W / Nozzle: 9.4 cm²; 1.7 cm²; 0.4 cm² / 40 to 42 ° C in the epidermis.	Time not mentioned/ 7 sessions/ once a week.
17.	Montesi et al, 2007³⁰	Abdomen, scapulohumeral region, face, buttocks	Aluma. Lumenis	Frequency not mentioned / 24 J/ 0.54 cm2 and 1.5 cm2/ Temperature not measured.	Time not mentioned/ 6 to 8 sessions/ Twice a month
18.	Nahm et al, 2004³¹	Face	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2/ 35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 1 session.
19.	Narins and Narins. 2003³²	Forehead and cheeks.	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2/ 35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 1 session.
20.	Esparza and Gomez. 2003³³	Face	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2/ Temperature not measured.	40 minutes/ 1 session.
21.	UweWollina. 20 ll³⁴	Face	RF-refacing ™ (Meyer-Haake Medical Innovations	2.2 MHz / 8-12 W / Nozzle: 8. 15 and 20 mm diameter/ 35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 3 sessions/ every 15 days.
22.	Bogle et al, 2007³⁵	Lowe part of the face	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2/35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 70 minutes/ 1 session.
23.	Fritz et al, 2004³⁶	Nasolabial fold, marionette lines, cheeks, chin.	ThermaCool TC/Thermage	6 MHz / 330 W / Nozzle 1 cm2/ 35 ° C to 45 ° C in the epidermis.	Time not mentioned/ 11 patients - 1 session and 9 patients - 2 sessions.
23.	Ruiz-Esparza et al, 2004³⁷	Periorbital region, lower eyelids	ThermaCool TC/Thermage	6 MHz /330 W / Nozzle 1 cm2/ 35 ° C to 45 ° C in the epidermis.	10 minutes/ 1 session.
24.	Kaplan et al, 2009³⁸	Face, neck, arm and abdomen.	TriPollar/PollogenLtda	1 MHz / 30 W / Nozzle not mentioned/ 40 to 42° C in the epidermis.	Time not mentioned/ 4 to 11 sessions.
25.	Chipps et al, 2013³⁹	Face and neck.	Pelleve Skin Tightening System	4 MHz/ Power not mentioned/ Nozzle not mentioned/41°C to 43 ° C in the epidermis.	Time not mentioned/ 2 sessions/ every 30 days.
26.	Edwards et al, 20 12⁴⁰	Face	ThermaCool TC/Thermage	6 MHz/ 330 W/ Nozzle 3 cm2/ 40°C in the epidermis.	Time not mentioned/ 1 session.
27.	Suh et al,20 1 3⁴¹	Face.	ThermaCool TC/ Thermage	6 MHz/ 330 W/ Nozzle 3 cm2/ 40°C in the epidermis.	Time not mentioned/ 4 sessions/ every 4 months.
28.	Taub et al, 20 12⁴²	Face.	Pelleve/ Ellman International	4 MHz / Power not mentioned/ Nozzle not men-tioned/45°C in the dermis	Time not mentioned/ 6 sessions.
29	Tay and Kwok. 20 09⁴³	Face.	PhotoBioCare. Thailand	3 MHz/100 W/ 1 cm2/40 °C to 45 °C in the dermis.	Time not mentioned/ 6 sessions/ every 2 weeks.
30.	Vega et al, 2013⁴⁴	Hands.	Pelleve/ Ellman Internationa	4 MHz / Power not mentioned/ Nozzle not men-tioned/45°C in the dermis	Time not mentioned/ 3 sessions/ every 2 weeks.

	Name	Manufacturer	Frequency	Power	Wave amplitude	Inductive or	Mono/bi/tripolar	Nozzle size
						capacitive
1.	Genotherm(Argentina)⁴⁵	CEC	1 MHz	240 W	Not provided	Capacitive	Bipolar	Not provided
2.	Genesis (Argentina)⁴⁶	Fundar	1 or 3	40 W	Not provided	Capacitive	Monopolar/Bipolar/ Tripolar	10 cm diameter
3.	Triatherm (Argentina)⁴⁷	CEC	1 MHz	60 W	Not provided	Capacitive	Tripolar	Not provided
4.	Splenda (Argentina)⁴⁸	Meditea	0.5; 0.8; 1 MHz	115 W	Not provided	Capacitive	Multipolar	Not provided
5.	Innovater (Argentina)⁴⁹	Meditea	0.5; 0.8; 1 MHz	115 W	Not provided	Capacitive	Multipolar	Not provided
6.	TopCavity (Italy)⁵⁰	Top Cavity	6 MHz	50W	Not provided	Inductive	Tripolar	50 mm
7.	Photogen System(Spain)⁵¹	Mesoestetic	1 MHz	150 J/cm2	Not provided	Capacitive	Monopolar and bipolar	3 cm diameter
8.	Pelleve (USA)⁵²	Ellman	4 MHz	120 W	Not provided	Capacitive	Monopolar and bipolar	5 mm /10 mm / 15 mm / 20 mm
9.	Multicel (Argentina)⁵³	Meditea	0.5 MHz	Not provided	Not provided	Not provided	Not provided	Not provided
10.	Thermacool (USA)⁵⁴	Thermage	6 MHz	200 J/cm2	Not provided	Capacitive	Monopolar and bipolar	0.25/1.0/1.5/3 cm²
11.	Freeze (Israel)⁵⁵	MP2	Not provided	Not provided	Not provided	Capacitive	Multipolar	Not provided
12.	VelaShape (USA)⁵⁶	ELOS	1 MHz	20 W	Not provided	Capacitive	Bipolar	Not provided
13.	Hooke (Brazil)⁵⁷	Ibramed	27.47 MHz	120 W	Not provided	Capacitive	Monopolar and bipolar	Not provided
14.	Hertix (Brazil)⁵⁸	KLD	0.64; 1.2 and 2.4 MHz	150 W	Not provided	Capacitive	Bipolar and Tripolar	Not provided
15.	Spectra G2 (Brazil)⁵⁹	Tonederm	0.65 MHz	10 and 30 W	Not provided	Capacitive	Monopolar	10 mm, 20 mm, 35 mm and a hexapolar with 72 mm
16.	New Shape (Brazil)⁶⁰	Bioset	1 MHz	50 W	Not provided	Capacitive	Bipolar	Not provided
17.	Light Plus (Brazil)⁶¹	SteticLine	8 MHz	Not provided	Not provided	Capacitive	Bipolar and tripolar	Not provided
18.	Apollo (Brazil)⁶²	Tripollar	1 MHz	50 W	Not provided	Capacitive	Tripolar	1 to 3 cm²
19.	RF Light Plus (Brazil)⁶³	SteticLine	1 MHz	Not provided	Not provided	Capacitive	Monopolar	Not provided

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	Author/ year	Objective	Sample / Groups	Endpoint variable
1.	Shapiro et al., 2012¹⁶	To evaluate the effectiveness of RF for the treatment of wrinkles.	37 subjects/ women/ 36 a 65 years. (No control group)	Wrinkles.
2.	Abrahan et al. , 2004¹⁷	To evaluate the effectiveness of RF for the treatment of wrinkles and laxity.	35 subjects/ 28 women and 7 men/ 35 to 65 years.(no control group)	Wrinkles and laxity.
3.	Rusciani et al. , 2007¹⁸	To evaluate the effectiveness of RF for the treatment of laxity.	93 subjects/ 83 women and 10 men/ mean 53,3 years.(no control group)	Laxity.
4.	Hsu et al.,2003¹⁹	To evaluate the effectiveness of RF for the treatment of laxity.	16 subjects/ 15 women and 1 men/ 43 to 73 years(no control group)	Laxity.
5.	Harth et al., 2010¹²	To evaluate the effectiveness of RF for the treatment of laxity.	30 subjects/ gender not mentioned/ age not mentioned (no control group)	Laxity.
6.	Bassichis et al., 2004²⁰	To evaluate the effectiveness of RF for the treatment of laxity.	36 subjects/ experimental group: 24 (23 women and 1 men; control group: 12 (gender not mentioned)/ age not mentioned	Forehead height .
7.	Lee et al., 201¹⁶	To evaluate the effectiveness of RF signals in photoaging (wrinkles, pigmentation, telangiectasia, laxity)	26 subjects/ 26 women/ mean 56 years(No control group)	Laxity, brightness and degree of elasticity.
8.	El-Domyati et al., 2011²¹	To evaluate the effectiveness of RF for the treatment of wrinkles.	6 subjects/ 6 women/ 47 to 62 years (No control group)	Wrinkles. Elastin and collagen quantity.
9.	Javate et al., 2011²²	To evaluate the effectiveness of RF for the treatment of wrinkles.	32 subjectsa/ 28 women and 4 men/ 29 to 71 years (no control group)	Wrinkles. Collagen quantity.
10.	Friedman et al., 2007²³	To evaluate the effectiveness of RF for the treatment of wrinkles and laxity.	16 subjects/ 16 women/ 29 to 66 years (No control group)	Wrinkles and laxity.
11.	Fitzpatrick et al. , 2003²⁴	To evaluate the effectiveness of RF for the treatment of wrinkles and laxity.	86 subjects/ 79 women and 7 men/ 35 to 70 years (no control group)	Wrinkles and laxity.
12.	Alster et al. , 2004²⁵	To evaluate the effectiveness of RF for the treatment of wrinkles and laxity.	50 subjects/ gender not mentioned/ mean 53,3 years(No control group)	Wrinkles and laxity.
13.	Carruthers and Carru-thers, 2007²⁶	To evaluate the effectiveness of RF for the treatment of laxity.	20 subjects /17 women and 3 men/ age not mentioned (No control group)	Laxity.
14.	Finzi and Spangler, 2005²⁷	To evaluate the effectiveness of RF for the treatment of laxity and wrinkles.	25 subjects/ 24 women and 1 men/ 33 to 68 years (no control group)	Laxity and wrinkles.
15.	Kushikata et al. , 2005²⁸	To evaluate the effectiveness of RF for the treatment of laxity.	85 subjects/ 85 women/ 31 to 68 years (no control group)	Laxity.
16.	Levenberg, 2010²⁹	To evaluate the effectiveness of RF for the treatment of laxity, wrinkles and fat.	37 subjects/ women/ 23 to 82 years (No control group)	Wrinkles, Laxity and localized fat.
	Instrument	Result	Justification	PEDro/ Level of evidence
1.	Pictures.	Decrease in wrinkles. Positive statistical difference.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
2.	Objective measurement of forehead height. Satisfaction questionnaire. Pictures.	Decrease in wrinkles and laxity. Positive statistical difference.	Thermal effect leads to production of collagen.	2/ Insufficient evidence.
3.	Pictures.	Decrease in skin laxity. Positive statistical difference.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
4.	Pictures. Satisfaction questionnaire.	No significant change. No statistical analysis.	Thermal effect leads to production of collagen.	2/ Insufficient evidence.
5.	Pictures. Fitzpatrick scale.	Decrease in skin laxity. Positive statistical difference.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
6.	Satisfaction questionnaire. Pictures. Brow's measurement.	Forehead height reduction. Positive statistical difference. Client dissatisfaction.	Thermal injury leads to the production of collagen .	4/ Limitada evidencia.
7.	Pictures. Medical evaluation. Scale of subjective improvement. Patient satisfaction .	Decrease in laxity, increased brightness and skin elasticity. Positive statistical difference.	Thermal injury .	2/ Insufficient evidence.
8.	Pictures. Skin biopsy.	Decrease in wrinkles and increased collagen. Positive statistical difference.	Thermal effect leads to production of collagen.	2/ Insufficient evidence.
9.	Pictures. Patient satisfaction. Histological analysis. Fitzpatrick scale	Decrease in wrinkles. Positive statistical difference.	Thermal effect leads to production of collagen.	2/ Insufficient evidence.
10.	Pictures.	Decrease in wrinkles and laxity. Positive statistical difference.	Thermal effect leads to production of collagen.	2/ Insufficient evidence.
11.	Pictures. Patient satisfaction. Fitzpatrick scale.	Decrease in wrinkles and laxity. No statistical analysis.	Thermal effect leads to production of collagen.	4/ Limitada evidencia.
12.	Pictures. Patient satisfaction.	Decrease in wrinkles laxity. No statistical analysis.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
13..	Pictures. Patient satisfaction	Decrease in laxity. No statistical analysis.	Thermal effect leads to production of collagen.	4/ Limitada evidencia.
14.	Pictures.	Decrease in wrinkles and laxity. No statistical analysis.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
15.	Pictures.	Decreased laxity. No statistical analysis.
16.	Pictures. Circumference measurements	Decreased laxity, wrinkles and localized fat. Positive statistical difference.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
	Author/ year	Objective	Sample / Groups	Endpoint variable
17.	Montesi et al., 2007³⁰	To evaluate the effectiveness of RF for the treatment of laxity.	30 subjects/ 26 women and 4 men/ 18 to 70 years (no control group)	Laxity and wrinkles and collagen quantity.
18.	Nahm et al., 2004³¹	To evaluate the effectiveness of RF for the treatment of laxity.	10 subjects/ 9 women and 1 men/ 39 to 62 years(no control group)	Laxity.
19.	Narins and Narins, 2003³²	To evaluate the effectiveness of RF for the treatment of laxity.	17 subjects/ 17 women/ 42 to 60 years (No control group)	Laxity.
20.	Ruiz-Esparza and Gomez, 2003³³	To evaluate the effectiveness of RF for the treatment of laxity.	15 subjects/ 15 women/ 41 to 68 years (No control group)	Laxity.
21.	Uwe Wollina, 2011³⁴	To evaluate the effectiveness of RF for the treatment of laxity.	20 subjects/ 20 women/ 34 to 73 years (No control group)	Laxity.
22.	Bogle et al., 2007³⁵	To evaluate the effectiveness of RF for the treatment of laxity.	66 subjects/ 66 women/ mean 35 years. (No control group)	Laxity.
23.	Fritz et al., 2004³⁶	To evaluate the effectiveness of RF for the treatment of laxity.	20 subjects/ 20 women/ 40 to 63 years. (No control group)	Laxity.
24.	Esparza et al. , 2004³⁷	To evaluate the effectiveness of RF for the treatment of laxity and wrinkles.	20 subjects/ 20 women/ 42 to 67 years. (No control group)	Laxity and wrinkles.
25.	Kaplan et al. , 2009³⁸	To evaluate the effectiveness of RF in fat reduction and collagen regeneration.	12 subjects/ 12 women/ 34 to 65 years. (No control group)	Laxity, localized fat and collagen quantity.
26.	Chipps et al., 2013³⁹	To evaluate the effectiveness of RF for the treatment of laxity and wrinkles.	49 subjects/ 45 women and 4 men/ 30 to 70 years.(no control group)	Laxity and wrinkles.
27.	Edwards et al., 2013⁴⁰	To evaluate the effectiveness of RF for the treatment of laxity.	64 subjects(no control group)	Laxity.
28.	Suh et al.,2013⁴¹	To evaluate the effectiveness of RF for the treatment of laxity and wrinkles	8 subjects/7 women and 1 men (No control group)	Laxity and wrinkles.
29.	Taub et al., 2012⁴²	To evaluate the effectiveness of RF for the treatment of laxity and wrinkles.	17 subjects/ gender not mentioned/ age not mentioned. (No control group)	Laxity and wrinkles.
30.	Tay and Kwok, 2009⁴³	To evaluate the effectiveness of RF for the treatment of laxity and wrinkles.	6 subjects/ 6 women/ 30 to 60 years. (No control group)	Laxity and wrinkles.
31.	Vega et al., 2013⁴⁴	To evaluate the effectiveness of RF for the treatment of laxity.	31subjects/ 31 women/ 40 to 65 years (No control group)	Laxity.
	Instrument	Result	Justification	PEDro/ Level of evidence
17.	Pictures. Patient satisfaction. Biopsy.	Decreased laxity. No statistical analysis.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
18.	Pictures. Patient satisfaction.	Decreased laxity. Positive statistical difference.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
19.	Pictures. Patient satisfaction.	Decreased laxity. No statistical analysis.	Thermal effect leads to production of collagen.	2/ Insufficient evidence.
20.	Pictures.	Decreased laxity. No statistical analysis.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
21.	Picture. Patient satisfaction.	Decreased laxity. No statistical analysis.	Thermal effect leads to production of collagen.	2/ Insufficient evidence.
22.	Pictures. Laxity rating. BTC2000 device (skin rigidity and energy absorption).	Decreased laxity. No statistical analysis.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
23.	Pictures.	Decreased laxity. No statistical analysis.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
24.	Patient satisfaction. Quality of life questionnaires.	Decreased laxity and wrinkles. No statistical analysis.	Thermal effect leads to production of collagen.	2/ Insufficient evidence.
25.	Pictures.	Decreased laxity, localized fat and increased collagen No statistical analysis.	Thermal effect leads to production of collagen.	3/ Insufficient evidence.
26.	Pictures. Patient satisfaction. Quality of life questionnaires.	Decreased laxity and das wrinkles. Positive statistical difference.	Thermal effect leads to production of collagen.	2/ Insufficient evidence
27.	Pictures. Patient satisfaction questionnaire.	Decreased laxity. Positive statistical difference	Thermal effect leads to production of collagen.	2/ Insufficient evidence
28..	Picture. Pictures. Satisfaction questionnaire. Glogau classification	Decreased laxity. No statistical analysis.	Thermal effect leads to production of collagen.	2/ Insufficient evidence
29.	Pictures. Satisfaction scale.	Decreased laxity and wrinkles. Positive statistical difference	Thermal effect leads to production of collagen.	3/ Insufficient evidence
30..	Pictures. Patient satisfaction	Decreased laxity and wrinkles. No statistical analysis.	Thermal effect leads to production of collagen.	2/ Insufficient evidence
31.	Pictures. Global esthetic improvement.	Decreased laxity. No statistical analysis.	Thermal effect leads to production of collagen.	2/ Insufficient evidence

Radiofrequency for the treatment of skin laxity: mith or truth*

Radiofrequency for the treatment of skin laxity: mith or truth^*