Accent™ Radiofrequency System (Alma Lasers Inc, Ceasaria, Israel; Fort Lauderdale, Fl)

Electric currents have been used in medicine for various purposes for more than a cen­tury. Lower frequencies have been used in biostimulation for atrial fibrillation, for example, due to their ability to cause spasms in muscle tissue. Radiofrequency (RF) is defined by

Table 16.3 Techniques to Control Optical Energy and Radiofrequency Devices*

• Ions or dipole molecules (RF)

• Natural biologic chromophore (optical energy)

• Method of electromagnetic energy application

• Electromagnetic power (watts)

• Exposure time (sec)

• Tissue resistance (RF)

• Tissue impedance (RF)

*Laser/pulsed light (optical energy) and radiofrequency devices can thermally modify the connective tissue of the skin [22].

high frequency electric currents (0.3-100 MHz ), and is efficacious in heating tissue in electrosurgery.

Since weakened connective tissue and diminished microcirculation play a role in the pathogenesis of cellulite, long-term correction of cellulite may be possible through these two instigators. The Accent™ (Alma Lasers, Ft Launderdale, FL) RF system is a device employed to reduce cellulite via volumetric thermotherapy. The device was approved by the FDA in April 2007 “for use in dermatologic and general surgical procedures for the noninvasive treatment of wrinkles and rhytids using combined treatment with unipolar and bipolar”. Although the FDA has approved this device for treatment of wrinkles, it is also marketed toward cellulite reduction.

The mechanism of action of radiofrequency waves is as follows. It has been hypothe­sized that thermal energy is capable of denaturalizing collagen. Through heating collagen at 65+ degrees Celsius, the protein’s bonds break and a transformation from a highly orga­nized crystalline structure to a disorganized gel occurs. While optical energy is dependent on the chromophore concentration of the skin in order to attain thermal tissue destruction, RF is reliant on the electrical properties of tissues [21]. There have been claims that RF is capable of both increasing adipose tissue disruption while noninvasively removing fat deposits in the absence of fat necrosis [21].

The Accent system has Bipolar and Unipolar RF handpieces and a RF generator (40.68 MHz) that improves cellulite through three mechanisms: (1) deep dermal heating, causing neocollagenesis and remodeling; (2) adipocyte apoptosis and disruption of fat cells via thermal effects; (3) lymphatic drainage and increased blood circulation. The Unipolar handpiece penetrates the tissue to a depth of 20 mm, heating the subcutaneous tissue with a RF power of 100-200 watts, and the Bipolar handpiece penetrates the skin superficially to a depth of 2-4 mm with a RF power of 60-100 watts. The Unipolar device also includes a thermo-electric coupling cooler (TEC) [21].

Before surgery, the treatment area is demarcated with 5 cm x 6 cm grids (15 seconds exposure time) or 10 cm x 6 cm grids (30 seconds exposure time), and the skin is lubricated with treatment oil to prevent friction between the applicator and the skin. The system is set at the appropriate watts and time settings, and the TEC is turned on. The technician begins application with horizontal sweeping strokes followed by vertical strokes until the preset time has expired. Epidermal temperature is monitored with a laser thermometer to tract treatment phases. In Phase I (Up-Slope) the patient’s skin is monitored until it reaches a temperature of ~410°C, after which Phase II (Maintenance) commences. During Phase II, the time of exposure and the energy level are reduced by 10-15% and three to five passes should be applied. Common side effects include patient perception of pain from the heat and erythema. After treatment, the patient is asked to rest for 10 minutes and is then free to go. The recommended treatment regimen is composed of six treatments, once every two weeks (Fig. 16.8).

There are several advantages to the Accent procedure. It is fast, virtually pain – free, and requires little to no recovery time. Several studies have validated the efficacy of the Accent RF system. In a study by del Pino et al., 26 healthy female patients aged 18-50 years received two treatment sessions 15 days apart, and real-time ultrasound scanning was used to assess the results. The ultrasound scanning device is able to determine the distance between the stratum corneum and the Camper’s fascia and from the stratum corneum and the muscle. The results illustrated that 68% of the treated patients experienced a 20% con­traction of subcutaneous adipose tissue volume. In addition, patient self-assessment revealed that most women were satisfied with their results, and the women who were the most content were those who had the highest grade of cellulite defects. The authors con­cluded that the ultrasound was the best tool for assessing the effects of the RF device, because it gave an image of the alterations in the subcutaneous tissues. The results of their study found an increased echodensity of the connective tissue structures, demonstrating that RF, as hypothesized, affects the collagen of the subcutaneous tissues [21].

Overall, the Accent RF system exhibits promising results with minimal side effects. Future clinical trials may validate its efficacy and make its use more widespread.