INTRODUCTION
Skin aging is a complex process. Chronological aging results from the cumulative effects of oxidative stress1 and genetic damage. Extrinsic factors, such as excessive exposure to sunlight and smoking contribute to the appearance of aging skin.3 Together, they reduce collagen in the skin and underlying connective tissue.4,5 The resulting loss of skin elasticity is responsible for the appearance of lines and rhytids, skin laxity and roughness.6 The process of photoaging can add skin mottling, lentigines, and precancerous lesions such as actinic keratoses.7 While loss of skin integrity can lead to significant health issues,8,9 the primary concern for people with aging skin is unattractive appearance which may decrease self-esteem and diminish quality of life.10 A wide range of treatments are available for aged skin including topical retinoids, soft tissue fillers, injectable neuromodulators, cosmeceuticals, chemical peels, and energy-based devices.7 As patients may present with multiple age-related skin issues arising at different depths in the skin, combined therapies that can target specific depths and sometime contradictory conditions should provide greater overall quality of patient care and improved patient satisfaction than any single treatment modality. lagen to contract and stimulates fibroblasts to synthesize new collagen and elastin,11 a crucial step in facial rejuvenation. A high-intensity precision radiofrequency (RF) device employing a bipolar microneedle electrode system is FDA-cleared for treating facial wrinkles (InfiniTM High-Intensity Focused RF; Lutronic Global, Boston, MA). When activated, an electric current travels between the positive and negative electrodes.Tissue resistance to the current generates heat, ultimately resulting in zones of coagulative damage that are limited to the tissue around the active areas of the needle tips. This results in immediate collagen contraction and triggers a natural healing response that replaces damaged tissue with healthier new skin. Another energy-based treatment is fractional laser therapy. Fractionation permits deeper tissue penetration leading to greater tissue contraction, collagen production and tissue re- modeling without adverse scar formation. Fractional lasers are also useful for treating photoaged skin and dyschromia.12 The fractional laser chosen for this study has been cleared for the treatment of actinic keratosis, rhytids of the face, neck and de?collete?, benign pigmented lesions, lentigos and freckles (LaseMDTM Non-ablative 1927nm Fractional Thulium Laser; Lu- tronic Global, Boston, MA). This device employs the principle of photothermolysis by which a specific wavelength of light is
