Prejuvenation with Monopolar Radiofrequency Treatment

Since the early 2000s, young individuals have increasingly embraced a preventive approach to aging called “prejuvenation”, proactively pursuing noninvasive treatments such as dermal fillers, laser skin rejuvenation, microdermabrasion, chemical peels, and dedicated skincare routines before visible signs of aging emerge.¹ Monopolar radiofrequency treatment could be a well-suited component of a prejuvenation regimen because it stimulates natural collagen production and remodeling, with little or no posttreatment downtime.^2,3 By supporting early maintenance and strengthening of the skin’s structure, monopolar radiofrequency devices may help prevent or delay the development of laxity and wrinkles.

Interest in aesthetic procedures and expectations regarding treatment strategies to prevent signs of aging may be evolving with social media trends.¹ In a search conducted on Instagram in October 2025, the authors found >10,000 posts tagged with #collagenbanking. Collagen banking describes the progressive accumulation of newly synthesized collagen to counteract the loss of dermal collagen associated with aging.

Clinicians encourage maintenance of collagen levels beginning in the mid- to late 20s, at which point collagen production starts to decline by 1% annually.⁴ Treatments that support collagen banking may be particularly attractive for patients with mild to moderate skin laxity who seek maintenance of their youthful appearance and gradual, natural-appearing improvement, with an extended duration of results. Because monopolar radiofrequency stimulates neocollagenesis,^5,6 it may be an effective modality for accumulating and preserving a reservoir of dermal collagen and a beneficial component of prejuvenation routines, although clinical validation remains necessary. 

OVERVIEW OF MONOPOLAR RF TREATMENT
In the following case, we used a 4th-generation monopolar radiofrequency system (Thermage FLX, Solta Medical) designed for noninvasive treatment of wrinkles and rhytids, including those in the periorbital or eyelid area.⁷ The device, cleared by the US Food and Drug Administration (FDA) in 2017 for the periorbital and eyelid indications, uses numerous tips to treat multiple body areas, including a 4-cm² tip to treat lines and wrinkles, a 0.25-cm² eye tip to treat wrinkles around the periorbital area or eyelid, and a 16-cm² body tip to treat large body areas (Table 1).

The treatment operates through a high-frequency electric current flowing from a single active electrode to a grounding pad placed on the body.^8,9 As this current meets tissue resistance (ie, impedance), it generates heat in the collagen-rich dermis that cleaves hydrogen bonds within the collagen triple helix. This results in immediate collagen fibril contraction that tightens the skin while initiating a wound-healing cascade that produces continued tightening through new collagen deposition for up to 6 months (Figure 1). 

When used properly, the device is safe for all skin types because this radiofrequency energy is not absorbed by melanin or vasculature.⁹ Since 2002, this technology has evolved to include features such as skin surface cooling through cryogen gas spray, vibration for comfort, and impedance matching for safety.²

PROPOSED MECHANISM OF PREJUVENATION AND COLLAGEN BANKING
The effects of a monopolar RF treatment on collagen deposition align with the proposed principles behind prejuvenation and collagen banking. The device delivers controlled heat to the dermis, where collagen is the most abundant protein.⁵ This thermal energy induces a wound-healing response that activates dermal fibroblasts, resulting in increased collagen synthesis.^5,6 In direct response to dermal heating, fibroblasts increase procollagen type I and III production, as well as heat shock protein 47, which assists in procollagen I maturation.⁶

Furthermore, indirect fibroblast stimulation occurs through heat-activated intracellular signaling, such as transforming growth factor–β (TGF-β), which triggers fibroblasts to produce collagen types I and III and fibronectin while reducing extracellular matrix protease production.^10-12 This heat-induced neocollagenesis augments and organizes the extracellular matrix, providing a structured environment for mechanical activation of fibroblasts that sustains continuous production of collagen.¹³ Clinical studies have reported significant increases in dermal collagen content 2 and 6 months after monopolar RF treatment, supporting the concept of collagen banking.^3,14

Given this mechanism of collagen remodeling and the growing interest in prejuvenation regimens, evaluating long-term clinical outcomes is essential to validate the device’s role in sustained maintenance of skin health. Clinical studies of monopolar RF treatments typically measure clinical outcomes up to 6 months after a single treatment.^3,15,16 However, in clinical practice, patients often undergo multiple treatments over a few years, warranting real-world examples and case studies to demonstrate long-term prejuvenation effects. 

In a retrospective study of 8 patients between 34 and 65 years old who received 3 to 7 sessions of monopolar RF treatments over 6 to 7 years, 88% experienced no worsening of wrinkles.¹⁷ Herein, we describe a clinical example of prejuvenation in a patient who received multiple monopolar RF treatments over time. 

PREJUVENATION REGIMEN
In November 2019, a woman in her mid-30s with Glogau type 1 photodamage as well as dermatochalasis and elastosis of facial and neck tissues presented to our clinic for monopolar RF treatment. The patient had previously undergone treatments with a 3rd-generation device (Thermage CPT, Solta Medical) to her entire face at a different clinic in 2017. At the 2019 visit, we treated the patient’s entire face and neck with the Thermage FLX device (900 total pulses with the Total Tip 4.0 cm²). The patient received 2 more treatments, in December 2021 (623 pulses with the Total Tip 4.0 cm²) and September 2024 (600 pulses with the Total Tip 4.0 cm²), totaling 4 treatments over 8 years. 

At each treatment visit, we reviewed the procedure, risks, and expectations of treatment with the patient and obtained informed consent. The right side of the face was treated first, followed by the left side. The device tip was checked for abnormalities after every 50 pulses. The patient received acetaminophen and analgesic gas (Pro-Nox, Carestream America).

In addition to these treatments, the patient presented to our clinic between 2017 and 2025 for several injections of neurotoxin (Botox, Allergan Aesthetics) and hyaluronic acid-based dermal filler (Juvéderm Voluma XC, Allergan Aesthetics), as well as various light-based treatments. A comprehensive timeline of all documented aesthetic procedures is shown in Table 2. 

TREATMENT OUTCOMES
Discomfort during treatment and erythema immediately after treatment were minimal, with no posttreatment edema observed.

Figure 2 shows representative photographs before monopolar RF treatment at each of the 3 visits at our clinic, and from 2 follow-up visits in 2025 (in February and April, ~5 and ~7 months after the last monopolar RF treatment, respectively). Sustained improvement without apparent aging was noted over 6 years. Notable improvements include brow elevation, reduced upper eyelid hollowing, and enhanced jawline definition, with only conservative dermal filler placement following the initial treatments. The midface has maintained its youthful appearance for 4.5 years without additional fillers.

DISCUSSION
This case represents a successful prejuvenation regimen wherein multiple minimally invasive procedures, inclusive of monopolar RF treatments, resulted in minimal to no signs of aging across 8 years. We hypothesize that a predominant contributor to the delayed skin aging was device-induced neocollagenesis that safeguarded the patient against age-related collagen depletion.

This case supports the inclusion of monopolar RF treatment in a prejuvenation regimen; however, ideal timing for successive rounds of treatments is yet to be determined. 

Several clinical studies have reported sustained improvement 6 months after a single monopolar RF treatment, which corresponds with increased dermal collagen content.^3,15,16 However, regarding the spacing of multiple treatments to maximize results, practitioners must rely on clinical experience to estimate optimal treatment intervals. In the previously mentioned retrospective study of 8 patients treated with multiple sessions,¹⁷ patients 30 to 49 years of age reported satisfaction with intervals of 2 to 3 years, whereas older patients preferred intervals of up to 1 year. Our patient underwent monopolar RF treatments at 2- to 3-year intervals, which, considering the patient’s young age and additional cosmetic treatments, were appropriate intervals for prejuvenation purposes. 

Although our case exemplifies the concept of collagen banking, which is of growing interest among patients seeking to maintain a youthful appearance, individual variation in collagen-synthesis capacity, skin quality, and healing response may influence outcomes. Age-related changes in fibroblast function and decreased growth factor responsiveness may limit the effectiveness of collagen banking in older patients. Future research should focus on optimizing treatment parameters for specific patient populations.

1. Haykal D, Nahai F, Cartier H. Prejuvenation: the global new anti-aging trend. Aesthet Surg J Open Forum. 2023;5:ojad061.

2. Chapas A, Biesman BS, Chan HHL, et al. Consensus recommendations for 4th generation non-microneedling monopolar radiofrequency for skin tightening: a Delphi consensus panel. J Drugs Dermatol. 2020;19(1):20-26.

3. Suh DH, Ahn H-J, Seo J-K, et al. Monopolar radiofrequency treatment for facial laxity: histometric analysis. J Cosmet Dermatol. 2020;19(9):2317-2324.

4. Nichols K, Scalise E, Brunner H. Collagen through the ages: encouraging collagen banking and skinvestments for your patients. Modern Aesthetics. May/June 2025;23-25. https://modernaesthetics.com/topics/injectables/collagen-through-the-ages/36079

5. Zelickson BD, Kist D, Bernstein E, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: a pilot study. Arch Dermatol. 2004;140(2):204-209.

6. Dams SD, de Liefde-van Beest M, Nuijs AM, et al. Heat shocks enhance procollagen type I and III expression in fibroblasts in ex vivo human skin. Skin Res Technol. 2011;17(2):167-180.

7. Thermage FLX user manual. Solta Medical, Inc; 2018.

8. Dayan E, Burns AJ, Rohrich RJ, et al. The use of radiofrequency in aesthetic surgery. Plast Reconstr Surg Glob Open. 2020;8(8):e2861.

9. Carruthers J, Fabi S, Weiss R. Monopolar radiofrequency for skin tightening: our experience and a review of the literature. Dermatol Surg. 2014;40(suppl 12):S168-S173.

10. Brown PD, Wakefield LM, Levinson AD, et al. Physicochemical activation of recombinant latent transforming growth factor-betas 1, 2, and 3. Growth Factors. 1990;3(1):35-43.

11. Yuan W, Varga J. Transforming growth factor-beta repression of matrix metalloproteinase-1 in dermal fibroblasts involves Smad3. J Biol Chem. 2001;276(42):38502-38510.

12. Varga J, Rosenbloom J, Jimenez SA. Transforming growth factor beta (TGF beta) causes a persistent increase in steady-state amounts of type I and type III collagen and fibronectin mRNAs in normal human dermal fibroblasts. Biochem J. 1987;247(3):597-604.

13. Varani J, Dame MK, Rittie L, et al. Decreased collagen production in chronologically aged skin: roles of age-dependent alteration in fibroblast function and defective mechanical stimulation. Am J Pathol. 2006;168(6):1861-1868.

14. Suh DH, Choi JH, Lee SJ, et al. Comparative histometric analysis of the effects of high-intensity focused ultrasound and radiofrequency on skin. J Cosmet Laser Ther. 2015;17(5):230-236.

15. Angra K, Alhaddad M, Boen M, et al. Prospective clinical trial of the latest generation of noninvasive monopolar radiofrequency for the treatment of facial and upper neck skin laxity. Dermatol Surg. 2021;47(6):762-766.

16. Bogle MA, Ubelhoer N, Weiss RA, et al. Evaluation of the multiple pass, low fluence algorithm for radiofrequency tightening of the lower face. Lasers Surg Med. 2007;39(3):210-217.

17. Suh DH, Lee SJ, Ryou JH, et al. Monopolar radiofrequency treatment in Asian skin: do multiple RF treatments over time have beneficial effects? An observational report with long-term follow-up in eight patients. Dermatol Surg. 2013;39(4):670-672.

Disclosures: Brandon Lee and Mindy Tran are employees of Cheng Plastic Surgery. Jacqueline T. Cheng is a speaker for Solta Medical and a founder of Cheng Plastic Surgery. This study was sponsored by Bausch Health Companies Inc. Medical writing support and editorial assistance were provided under the direction of the authors by Fingerpaint Medical and funded by Bausch Health Companies Inc. 

ACKNOWLEDGMENTS
The authors thank the patient for her participation.