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http://aes.sagepub.com/content/31/7/747The online version of this article can be found at:

DOI: 10.1177/1090820X11416807

2011 31: 747Aesthetic Surgery JournalJun Hyung Kim, Jin Wook Jeong, Daegu Son, Kihwan Han, So Young Lee, Tae Hyun Choi and David W. Chang

Percutaneous Selective Radiofrequency Nerve Ablation for Glabellar Frown Lines

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Facial Surgery

Aesthetic Surgery Journal31(7) 747 –755© 2011 The American Society for Aesthetic Plastic Surgery, Inc.Reprints and permission: http://www .sagepub.com/journalsPermissions.navDOI: 10.1177/1090820X11416807www.aestheticsurgeryjournal.com

Glabellar frown lines between the eyebrows are the result of overactive corrugator supercilii and procerus muscles that work to pull the eyebrows inferomedially. This pro-cess yields vertical lines (usually two) between the eye-brows, known as glabellar furrows. When these occur in an exaggerated fashion, they can become a serious aes-thetic concern for patients. Despite botulinum toxin1 and other injectable fillers2 being useful in softening these lines, these options provide only a temporary solution. More permanent interventions, such as muscle resection3 and surgical division of the motor nerves,4 may result in asymmetry, dimpling upon animation, and persistent pares-thesia. Furthermore, residual postoperative scars are una-voidable and take a long time to fade.

Percutaneous Selective Radiofrequency Nerve Ablation for Glabellar Frown Lines

Jun Hyung Kim, MD, PhD; Jin Wook Jeong, MD; Daegu Son, MD, PhD; Kihwan Han, MD, PhD; So Young Lee, MD, PhD; Tae Hyun Choi, MD, PhD; and David W. Chang, MD

AbstractBackground: The dynamic muscles of the glabellar region can be overactive, giving patients a “scowling” look and making them appear angry, worried, or stressed.Objective: The authors describe percutaneous selective nerve ablation, a minimally-invasive procedure for treatment of glabellar frown lines, and report results from a series of patients treated with the technique.Methods: From November 2007 to December 2009, 27 patients (22 women and five men) underwent percutaneous selective nerve ablation to improve glabellar frown lines. Initially, the surface pathway of the nerve to the corrugator supercilii and procerus was checked with a peripheral nerve stimulator. For percutaneous localization, a 22-gauge monopolar electrode was introduced into the lateral brow and cheek skin without incision. Short electrical stimulation (0.3-0.5 mA) was delivered to identify the proper lesion sites. Synchronous contraction of corrugator supercilii was elicited and radiofrequency nerve ablation performed (85°C, 70 seconds). In all patients, the frontal branch of the facial nerve and angular nerve were treated bilaterally. The improvement was evaluated with the Wrinkle Assessment Scale.Results: Mean patient age was 54.5 years, and mean follow-up time was 18 months (range, 12-26 months). One patient had superficial second-degree burns to the brow skin, which healed with conservative treatment. Two patients had temporary paresthesia that completely resolved in a few weeks without sequelae. The Wrinkle Assessment Scale indicated a statistically significant improvement in the glabellar frown lines (preoperative vs postoperative mean, 3.7 vs 1.8; P < .05).Conclusions: Although long-term studies are necessary to determine the ideal amount of energy delivery for maximum efficacy and time for treatment of glabellar frown lines, the study lends support for the safety and efficacy of percutaneous selective nerve ablation.

Keywordsglabellar lines, facial surgery, percutaneous selective nerve ablation, radiofrequency

Drs. Kim, Jeong, Son, and Han are from the Department of Plastic and Reconstructive Surgery, and Dr. Lee is from the Department of Rehabilitation Medicine, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Republic of Korea Dr. Choi is from the Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea. Dr. Chang is from the Department of Plastic Surgery, University of Texas, MD Anderson Cancer Center, Houston, Texas.

Corresponding Author:Dr. Jun Hyung Kim, 196 Dongsan Dong, Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, Dongsan Medical Center, Daegu 700-712 Republic of Korea. E-mail: [email protected]

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748 Aesthetic Surgery Journal 31(7)

As an alternative, we describe a minimally-invasive method for treating the glabellar area called percutaneous selective radiofrequency nerve ablation. Radiofrequency (RF) is a high-frequency current that is applied to neural tissue through a closed circuit. The current, produced by a generator, travels from the active electrode and returns to either the patient’s grounding plate (monopolar) or a nega-tive electrode built into the delivery needle (bipolar). The difference between these electrodes is the voltage, which generates an electric field that forces the ions in the tissue to move. The tissue then heats the electrode tip, which in turn absorbs heat from the tissue. An equilibration of the temperature between the tissue and electrode tip then occurs.5 Soft tissue ablation with RF energy has been widely applied during open and endoscopic procedures.6,7

MethOds

From November 2007 to December 2009, 27 patients underwent percutaneous selective RF nerve ablation for treatment of their glabellar frown lines. All patients were treated by Dr. Jun Hyung Kim at the Dongsan Medical Center in the Department of Plastic and Reconstructive Surgery at the Keimyung University School of Medicine. For RF nerve ablation, we procured a lesion generator, an electrode, and a grounding pad. The RF lesion generator we selected (PMG230; Baylis Medical Canada, Montreal, Quebec, Canada) can be used for both nerve stimulation and tissue coagulation. We elected to utilize the 22-gauge, straight, monopolar electrode, composed of an RF cannula and probe (Figure 1). A direct current nerve stimulator was incorporated into the generator, providing pulsed elec-trical stimuli of 2 Hz in a 200-millisecond duration and 0.5 to 2.0 mA.

There are two available modes for RF lesioning: pulsed and continuous. In this series, we selected the continuous mode, which causes coagulation necrosis at 60°C to 80°C. To achieve effective outcomes, it was important to place the electrodes near the target nerve, for a lesion of suffi-cient size.8 The lesion should be spherical around the active electrode and tapered at the tip so that only minimal lesioning occurs beyond the tip.

Operative Technique

To begin, a peripheral nerve stimulator (EZStim II, model ES400; Life-Tech International, Stafford, Texas) was applied to provide surface mapping of target nerves (ie, the frontal branch of the facial nerve to the corrugator supercilii and the angular nerve; Figure 2A and 2B). With 0.5 to 1.0 mA of stimulation of the target nerves, the path was “mapped” before skin penetration (Figure 2C). The nerve stimulator was placed on a “single twitch” setting with a frequency of 1 to 2 Hz.

After surface mapping, the patient was prepared and draped in sterile manner. Local anesthesia was generally comprised of 1% lidocaine with 1:100,000 epinephrine for

the skin over the probe insertion sites and for supraorbital and infraorbital nerve blocks. The patient was allowed to request supplemental anesthesia, depending on the extent of the procedure and his or her tolerance. The majority of our patients (93%) received intravenous sedation with propofol and fentanyl by an anesthesiologist.

Given the surface mapping results and general ana-tomical knowledge, we relied on two approaches to the target nerves. First, the inferior brow approach provided access for ablation from the frontal branch of the facial nerve to the corrugator supercilii. The eyelid skin was punctured at the level of the superior orbital rim, 10 mm lateral to the supraorbital notch in a vertical direction, with the system’s 22-gauge cannula and stylet (Figure 3A). The RF probe was inserted through the cannula and advanced through the dermis and orbicularis muscle. In severe cases, we sometimes selected a lateral brow approach but mainly relied on the inferior brow approach (Figure 3B).

A cheek approach was used for the ablation of the angular nerve. The cheek was punctured with the electrode on the midpupillary line and the electrode advanced toward the lateral border of the nose through the

Figure 1. Radiofrequency lesion generator system (PMG230; Baylis Medical Canada, Montreal, Quebec, Canada): (A) radiofrequency cannula: 22-gauge, 100-mm length, 10-mm active tip, straight; (B) stylet; (C) radiofrequency probe: 22-gauge, 100-mm length, straight.



Kim et al 749

subcutaneous tissue (Figure 3C). After the electrode was placed on the tissue, a short electrical stimulation (0.3-0.5 mA) was continuously delivered, and the electrode was moved along the path of the target nerve, to find the proper lesioning sites. With this method, synchronous contraction of the corrugator supercilii was evident. At least two lesioning sites were selected on each target nerve. Once the proper sites were determined, RF energy (85°C, 70 seconds) was delivered through the insulated

electrode tip. During treatment, a small, local, involuntary muscle contraction of the corrugator supercilii was often observed. In all patients, the frontal branch of the facial nerve and angular nerve were treated bilaterally.

After lesioning was complete, the status of the glabellar lines was assessed. If additional lesioning was required, the electrode was replaced and the remaining distal nerve restimu-lated. No sutures were placed. Topical antibiotic ointments and simple bandages were applied for dressing of the electrode

Figure 2. (A) Peripheral nerve stimulator (EZStim II, model ES400; Life-Tech International, Stafford, Texas). (B) External electrode for peripheral nerve stimulation. (C) Surface mapping of the target nerve.




insertion points. To reduce postoperative edema (Figure 4), patients were advised to apply ice packs and remain in a semi-Fower’s position for 24 to 48 hours. Antibiotics and analgesics were prescribed if needed in the early postoperative period, typically twice per day for one to two days.

Clinical results are shown in Figures 5 and 6.

Assessment of Improvement

During preoperative evaluation, the characteristics of the glabellar skin creases (depth and orientation) and asym-metries were discussed with the patient, and photographs and video clips were taken. The glabellar frown lines were classified preoperatively and postoperatively according to the Wrinkle Assessment Scale (WAS) described by Lemperle et al (a scale of 0 to 5, where 0 is superior).9 Two independ-ent plastic surgeons scored the quality of the lines using baseline clinical photographs and follow-up photographs of at least one year. Paired t-tests were conducted, with significance set at 0.05. Analysis was performed with the SAS 8.2.

Results

The mean age of the patients (22 females and five males) was 54.5 years. The mean follow-up time was 18 months (range, 12-26 months).

Figure 3. (A) Lateral brow approach. (B) With an inferior brow approach, the skin is punctured 10 mm more lateral to the supraorbital notch, and the 22-gauge radiofrequency electrode is advanced. (C) With a cheek approach, the skin is punctured with the straight electrode at the midpupillary line, and the electrode is moved toward the lateral border of the nose.

Figure 4. Immediate postoperative swelling at the lesioning site (arrow).



Kim et al 751

Figure 5. (A) This 47-year-old woman presented for treatment of her glabellar lines, which were given a score of 4.0 on the Wrinkle Assessment Scale. (B) Eight months after treatment with percutaneous selective radiofrequency nerve ablation. (C) Twenty months after treatment, the patient has no furrow but shows some evidence of “bunching” in the glabellar area.

Figure 6. (A) This 56-year-old man presented for treatment of his glabellar lines, which were given a score of 5.0 on the Wrinkle Assessment Scale. (B) Thirteen months after treatment with percutaneous selective radiofrequency nerve ablation.




There were no significant complications (Table 1). Postoperative pain and swelling were mild to moderate and usually subsided within three days. In two patients, pain

and swelling lasted as long as seven days, and bruising was noted. All patients were able to return to normal activities 24 hours postoperatively. During follow-up, superficial

Table 1. Patient Demographics and Treatment Results

No. Age, y Sex Follow-up, mos Wrinkle Assessment Scale Adverse Events

Preoperative Postoperative

1 39 F 19 3 2

2 67 F 26 5 2 Severe swelling and bruising

3 58 F 17 3 1

4a 58 M 18 4 3 Temporary paresthesia

5 61 F 15 4 2

6 62 F 23 4 1

7 59 F 17 3 1

8 55 F 21 3 2

9a 58 F 19 4 3

10 55 M 20 4 2

11 45 F 21 3 1 Temporary paresthesia

12 48 F 14 4 2

13 52 F 19 3 2

14b 56 M 18 4 2

15a 67 F 19 5 3 Severe swelling and bruising

16 49 F 21 3 2

17 48 F 17 4 1

18a 52 F 21 3 2

19 57 F 17 4 1

20a 54 M 15 4 3

21 47 F 20 4 2 Superficial second-degree burn

22b 56 F 13 5 1

23a 62 F 17 4 3

24 43 F 16 3 1

25 48 F 14 4 1

26 56 F 12 3 2

27 59 M 17 4 1

aResult lasting more than 12 months. bAblation performed with blepharoplasty.



Kim et al 753

second-degree burns at the electrode insertion point were seen in one patient, but these healed with conservative treatment (Figure 7). Two patients experienced temporary paresthesia, which completely resolved within a few weeks without sequelae.

WAS analysis showed a statistically significant improve-ment in the glabellar frown lines, from a preoperative mean value of 3.7 to a postoperative mean value of 1.8 (P < .05). In 21 patients (78%), the effect lasted over 12 months.

disCussiOn

Deep glabellar frown lines can make patients appear older or distressed (angry), even in younger people who have no other obvious signs of aging. Numerous techniques have been proposed for the correction of these lines, including botulinum toxin injection, filler injection, cor-rugator supercilii muscle resection, and surgical division of the motor nerves. Injections provide only temporary repair. Muscle resection, through either an endoscopic or transblepharoplasty approach, provides good exposure and allows direct surgical ablation in experienced hands; however, in inexperienced hands, the transblepharoplasty approach is typically inadequate for precise treatment of the corrugator muscles. Furthermore, the route to the cor-rugator muscles through a blepharoplasty incision is lengthy and somewhat tedious. Precise corrugator removal without injury to the surrounding tissues is difficult.

With the increasing popularity of botulinum toxin, der-mal fillers, and cosmetic lasers, minimally-invasive tech-niques have rapidly become the treatments of choice in many aesthetic procedures. RF is one novel, minimally-invasive method of treating glabellar lines. Specifically, RF nerve ablation may be preferable for patients with male

pattern baldness (who might wish to avoid scarring) and for those who have undergone a previous forehead lift or upper blepharoplasty without adequate muscle resection.

Glabellar frown lines are produced by the action of the corrugator supercilii and the procerus. The corrugator is a small, pyramid-shaped muscle composed of two heads and located at the medial side of eyebrow. The lateral transverse head of the corrugator is innervated by the frontal branch of the facial nerve. At the supraorbital notch, the “twigs” of the frontal branch run a horizontal course toward the superolateral aspect of the corrugator within 2.8 to 25 mm.10 To ablate these twigs, multiple ablation sites were required with a lateral brow approach, but an inferior brow approach (Figure 3) required only single side for ablation, with back-and-forth movement of the electrode.

The procerus arises from the fascia of the nasal bone and the lateral nasal cartilage; it joins the skin over the lower part of the forehead, between the eyebrows. According to Caminer’s studies, the zygomatic branch of the facial nerve is destined to supply the inferior aspect of orbicularis oculi muscle. Small twigs pass upward to sup-ply the more medial fibers of the orbicularis. At the medial aspect of the zygomaticus major, the zygomatic and buc-cal branches of the facial nerve join to supply the procerus at the level of the medial canthus and the oblique head of the corrugators on its superficial inferior aspect.11 This joining of the branches forms the angular nerve, and this dual supply system is thought be the cause of recurrence after previous selective neurectomy.

In our approach, we ablated the nerve innervations of the corrugators along with the frontal branch of the facial nerve and the angular nerve, which limited the contrac-tion of the procerus. This dual ablation lends efficacy, longevity, and favorable results with minimal recurrence. Our patients showed improvement in their transverse

Figure 7. (A) In one patient, superficial second-degree burns at the electrode insertion point were noted after radiofrequency nerve ablation. (B) Ten months after treatment, the burn wound was completely healed with conservative treatment.




wrinkles and mild elevation of their brow position, presumably caused by deactivation of the brow depressor muscles.

Traditionally, localization of the peripheral nerve has been achieved by identifying anatomical landmarks. Various methodologies, including electrical nerve stimula-tion and ultrasound guidance, can be used to improve accuracy in the identification of the peripheral nerve. A peripheral nerve stimulator (like the one in our study) is a handheld device that supplies direct electrical current to an electrode. With the aid of this device, the path of many superficial peripheral nerves can be mapped before skin penetration by stimulating the motor component of the peripheral nerve with an output of 0.5 to 1.0 mA. To deter-mine the optical placement of the electrode, minimal stimulation current is important. With a minimal stimula-tion current (0.49 mA), the distance between the electrode and the nerve was 0.09 mm in width and 1.84 mm in depth.12 Ability to stimulate the nerve at low amperage (< 0.5 mA) indicates an extremely close position to the nerve.13 With surface mapping and percutaneous localiza-tion of the target nerve before ablation, we were able to readily identify the distal nerve supplying the corrugators and procerus, which allowed us to avoid injuring the wrong nerve elements and provided a considerable safety margin.

The electrode size and configuration, the rate of thermal equilibrium, the generated temperature, and the patient’s tissue characteristics are all important in determining the proper lesion size. One in vivo study showed that RF lesions of 45°C to 85°C produced nonselective destruction of nerve fibers and that RF lesions of over 90°C were asso-ciated with steam formation, charring, and sticking.14 With a temperature monitoring system, this problem is easily avoided. The most significant lesion expansion has been shown to occur between zero and 60 seconds at the target temperature.15 A 22-gauge, 10-mm, active-tip, insu-lated monopolar electrode with 90-second duration can produce a spherical lesion of 4-mm width at 80°C,16 and 180° of rotation of the electrode can increase the width of the lesion.17 To properly increase the lesioning area, the electrode must be placed parallel to the nerve. Larger and more complete lesions are associated with longer treat-ment duration for glabellar lines. Based on data from previous studies, we performed the nerve ablation at 85°C for 70 seconds.

There have been other reports of successful treatment of glabellar frown lines with RF nerve ablation,18-23 but most are from studies with bipolar or larger electrodes. The advantages of a 22-gauge monopolar electrode for target nerve ablation are that (1) no scars are left at the electrode puncture sites, (2) multiple sites can be approached via different angles, (3) placement of the elec-trode is less painful than with 18-gauge bipolar or 20-gauge electrodes, and (4) postoperative care is simple and adverse reactions (including bruising, ecchymosis, and swelling) are minimal.

In performing RF nerve ablation, there are several pre-cautions to keep in mind. First, diffusion of local anesthetic

and administration of muscle relaxers under general anes-thesia can make target nerve stimulation difficult. If local anesthetics are infiltrated too deeply or too much is admin-istered, the target nerve cannot be stimulated. Second, since the procedure can be painful (especially in the first few seconds), adequate sedation is essential for the patient’s comfort, as well as for maintaining placement of the elec-trode during lesioning. Third, to prevent skin burns during the procedure, the depth and location of the electrode should be checked. Marking the electrodes at intervals of 1 cm is very helpful for checking the depth intraoperatively (Figure 8). Last, to obtain better and longer-lasting results, combination treatment with surgical wire dissection and filler injection is helpful.

COnClusiOns

Although further long-term study is warranted to deter-mine the ideal amount of energy and time for delivery of RF ablation for the treatment of glabellar frown lines, our results demonstrate the safety and efficacy of this mini-mally-invasive technique in a series of 27 patients.

disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

Figure 8. To prevent the complications shown in Figure 7, the electrode can be marked at intervals of 1 cm to ensure appropriate depth during the procedure.



Kim et al 755

ReFeRenCes

1. Rzany B, Ascher B, Monheit GD. Treatment of gla-bellar lines with botulinum toxin type A (Speywood Unit): a clinical overview. J Eur Acad Dermatol Venereol 2010;24(suppl 1):1-14.

2. Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid fillers in facial cosmetic surgery: review and techni-cal considerations. Plast Reconstr Surg 2007;120(suppl 6):41S-54S.

3. Guyuron B, Michelow BJ, Thomas T. Corrugator super-cilii muscle resection through blepharoplasty incision. Plast Reconstr Surg 1995;95:691-696.

4. Isse NG. The endoscopic approach to forehead and brow lifting. Aesthet Surg J 1998;18:462-469.

5. Cosman ER Jr, Cosman ER Sr. Electric and thermal field effects in tissue around radiofrequency electrodes. Pain Medicine 2005;6:405-424.

6. Sanou R, Bazin C, Krakowski I, et al. Radiofrequency ablation for palliation of soft tissue tumor pain. J Radiol 2010;91:281-286.

7. Heywood RL, Khalil HMB, Kothari S, Chawda S, Kotecha BT. Radiological airway changes following bipolar radio-frequency volumetric tissue reduction. J Laryngol Otol 2010;124:1078-1084.

8. Ko HY, Shin YB, Lee SH. Effect of radiofrequency lesion-ing on peripheral nerve conductivity in relation to dis-tance between lesioning electrode and target tissue in rats. J Korean Acad Rehabil Med 2004;28:449-453.

9. Lemperle G, Holmes RE, Cohen SR, Lemperle SM. A classification of facial wrinkles. Plast Reconstr Surg 2001;108:1735-1750.

10. Hwang K, Kim YJ, Chung IH. Innervation of the corruga-tor supercilii muscle. Ann Plast Surg 2004;52:140-143.

11. Caminer DM, Newman MI, Boyd JB. Angular nerve: new insights on innervation of the corrugator superci-lii and procerus muscles. J Plast Reconstr Aesthet Surg 2006;59:366-372.

12. Sung DH, Kwon JY, Chang DY, Lee YT. Standardiztion of the nerve localization technique in percutaneous peripheral nerve blockade. J Korean Acad Rehab Med 2000;24:259-266.

13. Urmey WF. Using the nerve stimulator for peripheral or plexus nerve blocks. Minerva Anestesiol 2006;72:467-471.

14. Eric RC, Blaine SN, Janice OL. Theoretical aspects of radiofrequency lesions in the dorsal root entry zone. Neu-rosurgery 1984;15:945-950.

15. Kline M. Radiofrequency techniques in clinical practice. In: Walldman SD, Winnie AP, eds. Interventional Pain Management. Philadelphia, PA: WB Saunders; 1996;201-211.

16. Gray DB, Bajwa ZH. Facet block and neurolysis. In: Walldman SD, Winnie AP, eds. Interventional Pain Management. 2nd ed. Philadelphia, PA: WB Saunders; 2001:446-479.

17. Racz GB, Stanton-Hicks M. Lumbar and thoracic sympa-thetic radiofrequency lesioning in complex regional pain syndrome. Pain Pract 2002;2:250-256.

18. Utley DS, Goode RL. Radiofrequency ablation of the nerve to the corrugator muscle for elimination of glabel-lar furrowing. Arch Facial Plast Surg 1999;1:46-48.

19. Wade F, Edgar FF, Ronald LM. Radiofrequency ablation of facial nerve branches controlling glabellar frowning. Dermatol Surg 2009;35:1908-1917.

20. Cho SB, Lee SJ, Hwang YS, Lee KC, Oh SH. Radiofrequency-selective nerve ablation for glabellar frown lines in east asian patients. Clin Exp Dermatol 2009;34:e393-e394.

21. Newman J. Radiofrequency ablation for the reduction of glabellar frowing. Facial Plast Surg 2010;26:266-273.

22. Gregorio HZ, Jose GS. Percutaneous radio-frequency neuroablation in plastic surgery. Aesthet Plast Surg 1994;18:41-48.

23. Hwang YS, Kim YS, Roh TS, Tark KC, Lee KC. Treatment of glabellar frown lines using selective nerve block with radiofrequency ablation. J Korean Soc Plast Reconstr Surg 2009;36:205-210.



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