MINIMALLY-INVASIVE, PAINLESS AND EFFECTIVE COMBINED PROTOCOL Noura Lebbar, MD, explains how she uses endo-radiofrequency, HA injections, and chemical peels to rejuvenate the face and neck

Noura Lebbar, MD, explains how she uses endo-radiofrequency, HA injections, and chemical peels to rejuvenate the face and neck

NOURA LEBBAR, MD Cosmetic Surgeon, Anti-Aging Medicine; Milan, Italy
[email protected]

NON-INVASIVE AND MINI-INVASIVE PROCEDURES REPRESENT new trends in the aesthetic market. Patients want to look younger with a fresh look without any downtime, preferably in one session, as they often have busy schedules. These high expectations led me to create an efficient combined protocol that immediately improves skin texture, lifts the skin, and stimulates fibroblasts to produce new collagen and elastin fibres over the 3 months following treatment.

Material and methods

For this procedure, I chose a 73 year-old female patient with grade II face sagging and grade III deep skin wrinkles in order to challenge the combined protocol.
I began the combined procedure by performing endo-radiofrequency (ThermaDAS technolux, Italy) using one unique entry point on the zygomatic area of each half face. Prior to this, I injected Klein’s solution 5ml into each half face to improve the patient’s comfort during the procedure. Klein’s solution is mainly used for liposuction, but I find it useful in this scenario. It is compounded in 1 litre of saline solution and I add 1 mg adrenaline, 800 mg lidocaine, and sodium bicarbonate 40 mEq to keep the Klein solution less acidic and less painful while it is being injected. I am careful not to inject a large volume to avoid creating a facial oedema.
The endo-radiofrequency was then applied with a 20 G smooth cannula using the same entry point as the anaesthesia. The temperature should reach 55°C, and the middle and lower face should be treated uniformly, with the superficial skin reaching a temperature of 42°C. The cannula should be located on the superficial fat layer throughout the procedure to allow for a deeper stimulation of fibroblasts and permit a reaction to occur along the skin tension lines, leading to a face lifting effect. The first step of the procedure should last 30 minutes (15 minutes for each half face); dividing every half-face into five lines, I heated each line for 3 minutes.

The device used combines plasma energy, radio-frequency needles, and endo-radiofrequency. ThermaDAS made in Italy by Technolux, is efficient because the thermo-couple (cannula with a warmed tip) reaches the superficial subcutaneous layer with a controlled temperature between 40–57°C. Important collagen production and stem cell stimulation is enhanced by submitting the deeper skin layers to such temperatures. The procedure is very safe because of the perfect control of the temperature.

Once the intra-lifting step of the combination with endo-radiofrequency was completed, I proceeded with skin biostimulation. Using the same entry point, I injected a total of 2 ml of non-cross-linked hyaluronic acid (20mg/ml), dividing 1 ml for each half face into five lines to distribute the HA uniformly on the treated area. The HA allowed
me to rebuild the lost volume in the aged skin. Furthermore, I injected 5 ml of pure polynucleotides to improve tissue regeneration. In the third phase of my protocol, I superficially applied TCA trichloroacetic acid stabilised with hydrogen peroxide on the whole face and neck using nitrile gloves to provide supplementary skin lifting, lighten the skin, and to stimulate the superficial skin regeneration layers thanks to the peeling effect. All the treatments used in my protocol are designed to give the maximum result with the minimum down-time.

Figure 1 (A) Before, (B) after treatment
Figure 2 (A) Before, (B) after endo-radiofrequency and biostimulation


Immediately after the procedure, the lifting effect was visible around the treated area. Additionally, skin tone and texture were also improved. The patient didn’t complain of any pain, bruising, redness or itching during or after the procedure. A very smooth oedema was notable over the two proceeding days from the procedure. No additional side-effects were noted.

The maximum result was visible 3 months after the procedure, as this is the length of time required for the fibroblasts and collagen production initiated by the treatment to take effect. The patient was highly-satisfied.


The three-dimensional skin biostimulation assisted with endo-radiofrequency is a very innovative protocol combining two regenerative techniques: the controlled tissue heating induces new skin tension, while the second phase provides the essential ingredients to produce new collagen and elastin fibres. Intra-lifting is a painless and safe procedure that aims to tighten the skin, improve the appearance of wrinkles and fine lines, and reduce skin laxity due to its deep fibroblast stimulation.

This very innovative protocol has multiple advantages, including its ability to treat all skin types all year round, suitability for very mature skin, allows the practitioner to optimise sessions by providing more treatments at the same time, to reshape face contouring and create volume in the same session, and gives an immediate and visible improvement with little to no downtime.