Dermatology, May 2006

Graeme Lipper, MD


May 01, 2006

Dermatologic Surgery

Painless, Nonablative, Immediate Skin Contraction Induced by Low-Fluence Irradiation With New Infrared Device: A Report of 25 Patients

Ruiz-Esparza J
Archives of Dermatology. 2006:32;601-610

Nonablative rejuvenation (NAR) is rapidly supplanting traditional ablative methods such as laser skin resurfacing for the treatment of photoaging and skin laxity. In addition to the obvious benefits of reduced downtime and rare adverse events, nonablative lasers and radiofrequency devices also provide flexibility by allowing skin surgeons to treat off-face sites such as the neck and extremities without safety concerns. In this case series of 25 patients with facial laxity, Ruiz-Esparza reports immediate and prolonged skin tightening using a recently developed infrared light source (Titan; Cutera Inc; Brisbane, California). In contrast to alternative radiofrequency technologies, he notes that the infrared device produced nonablative skin tightening with negligible patient discomfort.

Twenty-five volunteer patients (23 female; age range: 44-75 years; skin types I-IV) comprised the treatment group, and these subjects received between 1 and 3 sessions at fluences ranging between 20 and 40 J/cm2. Treatment areas included eyebrow lifting only (n = 3); eyebrow, cheek, and neck laxity (n = 21); and lower face only (n = 1). All of these treatments represent off-label uses of a US Food and Drug Administration-approved device (Titan). Outcome measures included laxity improvement assessed by a blinded investigator using a quartile scale (excellent, moderate, minimal, or no improvement) and patient self-assessment. Photographic assessments were made immediately after treatment, less than a week after treatment, "several weeks" after treatment, and up to 12 months after treatment.

Almost all patients (22 of 25) showed immediate skin tightening; photographic results were graded as excellent (n = 13), moderate (n = 3), minimal (n = 6), and no results (n = 3). These results were noted to be durable at follow-up periods ranging from "several weeks" to 12 months. Treatments were well tolerated, with patients noting minimal discomfort. Three patients developed "isolated small, superficial second-degree burns" that healed without consequence. All patients expressed satisfaction with the procedure.


The Titan device contains an infrared lamp handpiece, delivering up to 40 J/cm2 of infrared light (1100-1800 nm) over several seconds. This energy is delivered in a steady fashion through a large chilled sapphire window tip (1 cm x 1.5 cm). In contrast to nonablative radiofrequency devices,[1,2] such as the ThermaCool system (Thermage; Hayward, California), the Titan system delivers lower fluences over a longer time, gradually heating the dermis. Because infrared energy is absorbed by tissue water, this system is hypothesized to alter collagen from a triple helix-crystalline structure into a constricted, random coil structure, resulting in immediate tissue tightening. In contrast, delayed improvement is attributed to new collagen synthesis over a period of months.

The case series reported by Ruiz-Esparza suggests clinical efficacy, but should be interpreted with caution. Significant study limitations include the lack of internal or external controls, standardized long-term follow-up, or histologic confirmation of posttreatment collagen contraction (the proposed mechanism of infrared-induced immediate skin contraction). Furthermore, some patients received single treatments while others received multiple treatments, and treatment parameters varied from subject to subject, as did follow-up (several weeks" to 12 months).

Future studies should aim to confirm both immediate tissue tightening as well as short-term (weeks) and long-term (6 months+) tissue effects, using objective criteria to document efficacy. Such studies must use consistent treatment parameters, treatment numbers, treatment intervals, and follow-up.


  1. Fitzpatrick RE, Geronemus R, Goldberg D, et al. First multi-center study of a new nonablative radiofrequency device to tighten facial tissue. Lasers Surg Med. 2003;15:36.

  2. Zelickson BD, Kist D, Bernstein E, et al. Histological and ultrastructural evaluation of the effects of radiofrequency-based nonablative dermal remodeling device. Arch Dermatol. 2004;140:204.



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