Novel Treatment Using Intradermal Radiofrequency and Hyaluronic Acid Filler to Correct Marionette Lines.

Dear Editor:

Aging results in anatomical changes to the face. The main change observed in the lower third of the face is ptosis of the labial commissure, which results in a triangular depressed area at the corner of the mouth, increased mentolabial sulcus, the formation of marionette lines, decreased the concavity between the jaw and neck, and noticeable platysma banding1. Cosmetic rejuvenation to correct marionette lines has evolved. Over the past five years, intradermal radiofrequency (RF) has become a common modality for reducing cutaneous sagging and wrinkling. A recent study2 demonstrates combination therapy with hyaluronic acid (HA) filler and intradermal RF results in greater and longer improvement of the nasolabial folds than HA monotherapy. Therefore, we tested intradermal RF and HA filler combination therapy with the aim of increasing volume and correcting marionette lines.

A 40-year-old woman unhappy with her marionette lines sought therapy (Fig. 1A). She had never received filler injection or laser resurfacing. The first step of therapy involved intradermal RF treatments using new device (INNOfill; Pacific Pharma, Korea) at 18 W (level 7, 1 MHz, 5 passes) with an insulation-coated 27-gauge needle electrode. The needle electrode was inserted along the marionette lines using a fanning technique. After delivering the RF energy, HA filler (Juvederm; Allergan, Irvine, CA, USA) was injected by linear threading. Slight bleeding occurred at the insertion site, but this was resolved within several hours. The treatment was successful, and she was very satisfied with the cosmetic outcome (Fig. 1B).

Fig. 1

(A) Before treatment. (B) Marked improvement 3 months after intradermal radiofrequency treatment prior to hyaluronic acid filler injection.

New bipolar RF device is used in combination with HA filler injection. This combination therapy is expected to produce a potentially long-lasting effect of the filler. This device delivers RF via an intradermal needle that specifically creates tunnel-like coagulation canals that will hold and support the injected HA filler. In addition, on the basis of the well-known effects on fibroblast proliferation caused by RF, RF energy induces new collagen formation3. Several cases and studies corroborate the notion that treatment with RF devices is a safe and efficient solution for the treatment of wrinkles2 and scars4. The real innovation potential lies in the possibility of using this device in combination with other well-known methods in the cosmetic medicine, which has clear potential for improving the efficiency of several techniques. This approach provides a filling/lifting/smoothing effect, thus reducing the effects of aging.

The major limitation of this case is that treatment was applied to the whole face; the results would be stronger if half the face was treated with RF alone or filler alone for comparison. In order to evaluate the efficacy of intradermal RF with HA filler combination therapy for correcting marionette lines, comparison with monotherapy with RF or HA filler is necessary.

To our knowledge, this is the first case in which HA filler was combined with RF treatment to correct marionette lines. Indeed, large randomized controlled studies are necessary to confirm the results. In addition, further studies in different clinical settings are required to confirm the validity of this device in the aesthetic dermatological field.