How to Avoid Complications With Radiofrequency and Ultrasound-Based Technologies

“A lot of these treatments are what we say, ‘generally regarded as safe,’ because they're being employed in the public all the time. People are using them all the time. The issue is, once something is being done over and over again, you are going to have complications. Now you can't avoid the complications once they happen, but learning how to fix these complications is huge,” said Karan Lal, DO, MS, FAAD, in an interview at the 2025 American Academy of Dermatology (AAD) Annual Meeting in Orlando, Florida.

Lal, a double-board certified pediatric and cosmetic dermatologist at Affiliated Dermatology in Scottsdale, Arizona, the pediatric dermatology director for the Omni Dermatology Residency Program, a cosmetic-teaching faculty member at the Northwell Health Residency Program in New York, and a Dermatology Times Editorial Advisory Board member, recently presented “Complications of RF and U/S Devices” at AAD.

Radiofrequency (RF) and ultrasound-based technologies are generally considered safe. However, complications arise with increased use, making it necessary for clinicians to understand their prevention and management, according to Lal.

Lal’s Key Highlights

Radiofrequency-Based Treatments

RF technologies include monopolar, bipolar, and multipolar devices for skin tightening and fat reduction. Additionally, RF microneedling is frequently employed for facial and body rejuvenation. While effective, these treatments carry risks, particularly in patients with skin of color.

• Insulated vs. Non-Insulated Microneedling Tips
  • Patients with darker skin tones should be treated with insulated RF microneedling tips to prevent epidermal injury and burns.
  • Non-insulated tips allow backflow of energy, increasing the risk of post-inflammatory hyperpigmentation (PIH) and scarring.
• Grounding Pad Issues in Monopolar RF
  • Monopolar RF requires a grounding pad to maintain safe energy flow. If the pad loses contact due to patient sweating, energy dispersal can lead to blister formation and burns.
  • Ensuring adequate pad placement and monitoring for moisture buildup is critical.
• Device Safety in Skin of Color
  • Despite manufacturer claims, not all devices are safe for patients with skin of color. Clinicians should critically assess the technology, considering how RF energy interacts with melanin-rich skin.
  • If an adverse reaction occurs during treatment, stopping immediately can mitigate further complications.

Ultrasound-Based Technologies

Ultrasound treatments, including high-intensity focused ultrasound (HIFU) and high-frequency ultrasound, are non-invasive skin-tightening modalities. While they don’t penetrate the skin barrier, improper technique can lead to significant complications.

• Avoiding Burns with HIFU
  • Adequate coupling gel is essential for proper energy transmission.
  • Insufficient probe-skin contact can result in uneven energy distribution, causing first-degree burns and blistering.
• Protecting Ocular Structures
  • Ultrasound treatments are commonly used around the periorbital region. However, if improperly anchored, energy can be directed toward the eye, leading to ocular damage.
  • When treating the eye area, clinicians should:
    • Anchor the probe on bony structures (eg, orbital rim).
    • Ensure energy delivery is directed away from the eye.
• Preventing Nerve Injury Around the Mouth and Brow
  • HIFU treatments near the upper cutaneous lip and lateral brow can cause temporary motor nerve paralysis, particularly at high energies with multiple passes.
  • Adjusting depth settings and limiting energy delivery in nerve-dense areas minimizes the risk.