PEER-REVIEW | RADIOFREQUENCY | the face, neck, and décolleté9–10


Table 1 Assessment scales for vulvovaginal laxity and sexual satisfaction


MILLHEISER VAGINAL LAXITY SCALE


1 = Very loose


2 = Moderately loose 3 = Slightly loose


4 = Neither tight nor loose 5 = Slightly tight


6 = Moderately tight 7 = Very tight


past are somewhat out in the open and, as such, more


comfortably discussed in a clinical setting. In the past, treatment of vulvovaginal laxity and related aspects lay within a short spectrum heavily weighted at the ends, with non-invasive (but minimally effective) Kegel exercises to strengthen the pelvic floor versus costly, invasive surgery at the other end. A 2012 physician member survey conducted by the International Urogynecological Association (IUGA) assessed the attitudes and practices regarding vaginal laxity6


; of the


563 respondents, 84% stated belief that vaginal laxity was underreported, 95% believed vaginal laxity impacted patient sexual function, and 57% considered it to greatly affect quality of life. All respondents felt vaginal laxity was the dominant physical change experienced by subjects after vaginal delivery. As for treatment, all surveyed physicians recommended Kegel exercises along with physical therapy, with approximately 54% offering or recommending surgical intervention, although 83% of respondents were concerned about dyspareunia (painful sexual intercourse) as an associated risk of surgery. Only recently have alternatives appeared to fill the wide gulf between the two ends of the spectrum. The term ‘vaginal rejuvenation’ has arisen, and received a lot of attention and scrutiny within the emergence of novel modalities. Vulvovaginal rejuvenation with devices harnessing laser or radiofrequency (RF) energy (among others), as in aesthetic dermatology and plastic surgery on


MILLHEISER SEXUAL SATISFACTION SCALE


1 = None 2 = Poor 3 = Fair


4 = Good


5 = Very good 6 = Excellent


, is a fairly new concept with


real potential for success. Numerous studies in aesthetic medicine have demonstrated tissue contraction and determined a therapeutically ideal temperature range (40°C to 45°C) in which neocollagenesis (via the healing cascade) is stimulated without causing unnecessary damage to the skin or integral tissue structures. A landmark study by Millheiser and colleagues in 201011


Vulvovaginal rejuvenation with devices harnessing laser or


radiofrequency energy (among others), is a fairly


new concept with real potential for success.


investigated transurethral monopolar RF for vaginal laxity after vaginal childbirth. Subjects (n=24, age range 25 to 44) were premenopausal women and had at least one full term vaginal delivery. Investigators used a seven point vaginal laxity scale (vaginal laxity questionnaire, or VLQ) to assess subjective patient perception of laxity and improvement (with ratings of 1=very loose, 2=moderately loose, 3=slightly loose, 4=neither loose nor tight, 5=slightly tight, 6=moderately tight, and 7=very tight). A six point sexual satisfaction questionnaire (SSQ) was also administered to help evaluate perceived improvement in sexual satisfaction (rated as 1=none, 2=poor, 3=fair, 4=good, 5=very good, and 6=excellent). Cryogen cooling was used concurrently with the RF probe inside the vagina to manage potential unwanted thermal damage due to overtreatment. At 1 month post-treatment 67% of patients reported improvements of 2 to 4 points on the VLQ and all patients reported at least one point of improvement. By follow-up at 6 months, approximately 87% of subjects reported improvements of 2 to 4 points. Of the 12 subjects who had reported diminished sexual function following delivery, all reported notable improvement to sexual function as well. Sekiguchi et al.8


more recently reported on a


prospective study of low-energy RF for vaginal introital laxity of 30 premenopausal women (age range 21 to 52 years), each receiving a 30-minute treatment with evaluations at 6 and 12 months post-treatment. Statistically significant improvements in sexual function, vaginal laxity, and reductions in distress during sexual activity were noted at 6 months and maintained through the 12-month endpoint, with no adverse events reported. RF has also been employed successfully to treat stress incontinence12–13


. Transcutaneous temperature controlled


radiofrequency (TTCRF) brings with it numerous advantages for the treatment of skin laxity14


. RF is an


established modality for tissue tightening via stimulation of neocollagenesis, denaturation of collagen, contraction, and activation of the healing cascade. This was shown in a histological study of RF in animal studies15


. Thus, tissue


Figure 2 (A) Before and (B) after images of a multiparous woman, age 58 years, with prior vaginoplasty presenting with severe laxity of the vagina and labia majora, and atrophic vaginitis. Outcome after one treatment with TTCRF included statistically significant improvement in laxity with visible aesthetic improvement and complete resolution of atrophic vaginitis. This patient also no longer uses vaginal estrogens


18  August/September 2015 | prime-journal.com


temperature is modulated by controlling the power (the electrical voltage delivered to the RF electrode) in relation to tissue impedance, which raises tissue temperature in the proximity of the RF electrode. Thermistors and thermocouples within the treatment probe provide feedback to the device, which controls power to modulate energy deposition and maximize therapeutic relevancy without causing damage and minimizing the potential for patient discomfort. Unlike laser-based treatments, skin type (color or pigmentation) is not an issue with RF energy; and while it is proven


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