Patent Publication Number: US-2003236487-A1

Title: Method for treatment of tissue with feedback

Description:
RELATED APPLICATIONS  
     [0001] This application claims the benefit of priority to U.S. Provisional Application Serial No. 60/376,622, filed Apr. 29, 2002, entitled “Method for Treatment of Tissue with Feedback”, which is fully incorporated by reference herein. 
    
    
     
       TECHNICAL FIELD  
       [0002] The disclosed embodiments relate to a method for treating tissue using the delivery of energy that can be controlled or modified by patient feedback.  
       BACKGROUND  
       [0003] The human skin is composed of two elements: the epidermis and the underlying dermis. The epidermis with the stratum corneum serves as a biological barrier to the environment. The underlying dermis provides the main structural support of the skin. It is composed mainly of an extracellular protein called collagen. Collagen is produced by fibroblasts and synthesized as a triple helix with three polypeptide chains that are connected with heat labile and heat stable chemical bonds. When collagen-containing tissue is heated, alterations in the physician properties of this protein matrix occur at a characteristic temperature. The structural transition of collagen contraction occurs at a specific “shrinkage” temperature. The shrinkage and remodeling of the collagen matrix with heat is the basis for the technology.  
       [0004] Collagen crosslinks are either intramolecular (covalent or hydrogen bond) or intermolecular (covalent or ionic bonds). The thermal cleavage of intramolecular hydrogen crosslinks is a scalar process that is created by the balance between cleavage events and relaxation events (reforming of hydrogen bonds). No external force is required for this process to occur. As a result, intermolecular stress is created by the thermal cleavage of intramolecular hydrogen bonds. Essentially, the contraction of the tertiary structure of the molecule creates the initial intermolecular vector of contraction.  
       [0005] Collagen fibrils in a matrix exhibit a variety of spatial orientations. The matrix is lengthened if the sum of all vectors acts to distract the fibril. Contraction of the matrix is facilitated if the sum of all extrinsic vectors acts to shorten the fibril. Thermal disruption of intramolecular hydrogen bonds and mechanical cleavage of intermolecular crosslinks is also affected by relaxation events that restore preexisting configurations. However, a permanent change of molecular length will occur if crosslinks are reformed after lengthening or contraction of the collagen fibril. The continuous application of an external mechanical force will increase the probability of crosslinks forming after lengthening or contraction of the fibril.  
       [0006] Hydrogen bond cleavage is a quantum mechanical event that requires a threshold of energy. The amount of (intramolecular) hydrogen bond cleavage required corresponds to the combined ionic and covalent intermolecular bond strengths within the collagen fibril. Until this threshold is reached, little or no change in the quaternary structure of the collagen fibril will occur. When the intermolecular stress is adequate, cleavage of the ionic and covalent bonds will occur. Typically, the intermolecular cleavage of ionic and covalent bonds will occur with a ratcheting effect from the realignment of polar and non-polar regions in the lengthened or contracted fibril.  
       [0007] Cleavage of collagen bonds also occurs at lower temperatures but at a lower frequency. Low-level thermal cleavage is frequently associated with relaxation phenomena in which bonds are reformed without a net change in molecular length. An external force that mechanically cleaves the fibril can reduce the probability of relaxation phenomena and provides a means to lengthen or contract the collagen matrix at lower temperatures while reducing the potential of surface ablation.  
       [0008] Soft tissue remodeling is a biophysical phenomenon that occurs at cellular and molecular levels. Molecular contraction or partial denaturization of collagen involves the application of an energy source, which destabilizes the longitudinal axis of the molecule by cleaving the heat labile bonds of the triple helix. As a result, stress is created to break the intermolecular bonds of the matrix. This is essentially an immediate extracellular process, whereas cellular contraction can require a lag period for the migration and multiplication of fibroblasts into the wound as provided by the wound healing sequence. In higher developed animal species, the wound healing response to injury involves an initial inflammatory process that subsequently leads to the deposition of scar tissue.  
       [0009] The initial inflammatory response consists of the infiltration by white blood cells or leukocytes that dispose of cellular debris. Seventy-two hours later, proliferation of fibroblasts at the injured site occurs. These cells differentiate into contractile myofibroblasts, which are the source of cellular soft tissue contraction. Following cellular contraction, collagen is laid down as a static supporting matrix in the tightened soft tissue structure. The deposition and subsequent remodeling of this nascent scar matrix provides the means to alter the consistency and geometry of soft tissue for aesthetic purposes.  
       [0010] In light of the preceding discussion, there are a number of dermatological procedures which may lend themselves to treatments which deliver thermal energy to the skin and underlying tissue to cause a contraction of collagen, and/or initiate a wound healing response at or near the treatment site. There is a need for systems and methods utilizing patient feedback to control the delivery of energy in such procedures and treatments.  
       SUMMARY OF THE INVENTION  
       [0011] Embodiments of the invention provide a method and apparatus whereby energy is delivered to a tissue site to heat tissue to cause a contraction of collagen, and/or initiate a would healing response to reshape, tighten or rejuvenate tissue at the tissue site, wherein patient feedback is utilized to reduce the thermal injury to non target tissue and/or the patient&#39;s level of pain or discomfort resulting from the delivery of energy to the tissue site.  
       [0012] An embodiment provides a method whereby electromagnetic energy is delivered to a tissue site and the surface of the tissue site is cooled using a heat transfer fluid whereby a reverse thermal gradient is achieved within the tissue site sufficient to produce collagen contraction and/or a subsequent wound healing response within the tissue site. Patient feedback is utilized to control one of the energy delivery or cooling rate to reduce an amount of pain or thermal injury to the surface of the tissue site or non-target adjacent tissue.  
       [0013] Another embodiment provides a method whereby RF energy is topically delivered to a tissue site using an energy delivery device and the surface of the tissue site is cooled using a cooling or cryogenic fluid whereby a reverse thermal gradient is achieved within the tissue site sufficient to produce collagen contraction and/or a subsequent wound healing response within the tissue site. Patient feedback is utilized to control one of the energy delivery or cooling rate to reduce an amount of pain or thermal injury to the surface of the tissue site or non-target adjacent tissue.  
       [0014] Another embodiment provides a method whereby RF energy is topically delivered to a tissue site to produce collagen contraction and/or a subsequent wound healing response within the tissue site. Patient feedback is utilized to control the energy delivery to reduce an amount of pain or thermal injury to the surface of the tissue site or non-target adjacent tissue.  
       [0015] Yet another embodiment provides a method wherein patient feedback is used to titrate the delivery of energy to a target tissue site to produce heating of the subjacent dermis to contract a tissue collagen matrix within or adjacent the target tissue site.  
       [0016] Still yet another embodiment provides a method wherein patient feedback and a feedback module or processor are used to titrate the delivery of energy to a target tissue site to produce heating of the subjacent dermis to contract a tissue collagen matrix.  
       [0017] Another embodiment provides a method whereby energy is topically delivered produce heating of the subjacent dermis to contract a tissue collagen matrix and patient feedback is utilized to facilitate preservation of the epidermis.  
       [0018] Yet another embodiment provides a method whereby energy is topically delivered to produce heating of the subjacent soft tissue such as the subcutaneous fat layer, muscle fascia and muscle and to contract a tissue collagen matrix of the subjacent soft tissue, wherein patient feedback is utilized to facilitate preservation of the epidermis.  
       [0019] Still yet another embodiment provides a method whereby energy is topically delivered to produce heating of the subjacent soft tissue such as the subcutaneous fat layer to cause thermal lipolysis and patient feedback is utilized to optimize or increase lipolysis while substantially preserving or reducing injury to the epidermis or other skin layer.  
       [0020] Another embodiment provides a method whereby energy is topically delivered to produce heating of the subjacent dermis to contract a tissue collagen matrix to produce an amount of skin tightening and patient feedback is utilized to facilitate preservation of the epidermis or reduce an amount of epidermal injury or erythema.  
       [0021] Another embodiment provides an method whereby energy is delivered to a tissue site to heat tissue to cause a contraction of collagen, and/or initiate a wound healing response and patient feedback is utilized to reduce the thermal injury to non target tissue and/or the patients level of pain or discomfort resulting from the delivery of energy to the tissue site.  
       [0022] Still yet another embodiment provides a method whereby energy is delivered to a tissue site to heat tissue to cause a contraction of collagen, and/or initiate a would healing response and patient feedback in the form of a patient determined pain/thermal sensation scale is utilized to reduce the thermal injury to non target tissue and/or the patients pain or discomfort resulting from tissue heating.  
       [0023] Another embodiment provides an apparatus for treating the skin that comprises a template having a tissue interface surface and an energy delivery device coupled to the template. The energy delivery device is configured to be coupled to a power source. A sensor is coupled to at least one of the template, a tissue surface, the energy delivery device, the tissue interface surface or a power source coupled to the energy delivery device. A feedback control system is coupled to at least one of the power source or the sensor. The feedback control system is configured to utilize a feedback signal indicative of a level of pain or discomfort felt by the patient resulting from tissue heating or injury to titrate the delivery of energy to the tissue site.  
       [0024] Yet another embodiment provides a method whereby patient heat or pain perception is utilized as an indicator of energy delivery or net heat transfer to the tissue site. Patient pain or thermal sensation can be correlated to total energy delivery, energy delivery rates or net heat transfer rates (i.e. balance between heating due to energy delivery and cooling from a cooling media). A database can generated of one or more of these correlations and utilized to control or titrate the delivery of energy and/or cooling.  
       [0025] Still another embodiment provides a system for regulating a tissue treatment procedure using patient feedback comprising a processor, a database coupled to the processor and a control module coupled to at least one of the database or the processor. The database includes a plurality of records, at least one record of the plurality includes at least one tissue treatment parameter and a pain or thermal sensation level associated with the at least one treatment parameter. The control module is configured to control an energy delivery parameter responsive to an input from at least one of a patient or the database.  
       [0026] Still yet another embodiment provides a computer readable medium on which is stored a database. The database includes a plurality of records, at least one record of the plurality including at least one tissue treatment parameter and a pain or thermal sensation level associated with the at least one treatment parameter. The database is configured to be coupled to a control module or a control system configured to control an energy delivery parameter responsive to an input from at least one of a patient or the database.  
       [0027] Another embodiment provides a system for regulating a tissue treatment procedure using patient feedback comprising a computing means, a database means coupled to the computing means and a control means coupled to at least one of the database means or the computing means. The database means includes a plurality of records. At least one record of the plurality includes at least one tissue treatment parameter and a pain or thermal sensation level associated with the at least one treatment parameter. The control means is configured to control an energy delivery parameter responsive to an input from at least one of a patient or the database means.  
       [0028] Yet another embodiment provides a method for energetically treating a tissue site comprising delivering energy to the tissue site using an energy delivery device; utilizing patient feedback to titrate the delivery of energy to the tissue site to reduce injury to a surface of the tissue site; and imparting a thermal injury to a portion of tissue within the tissue site.  
       [0029] Still yet another embodiment provides a method for treating a tissue site comprising delivering energy to a target tissue site of a patient using an energy delivery device; receiving feedback indicative of a patient pain or thermal sensation level; utilizing a database of digitally encoded correlations between at least one tissue treatment parameter and an associated pain or thermal sensation level to titrate the delivery of energy to the tissue site to reduce injury to a surface or layer of the tissue site; and imparting a thermal injury to a portion of tissue within the tissue site.  
       [0030] Another embodiment provides a system for regulating a tissue treatment procedure using erythema feedback comprising a processor, a database coupled to the processor and a control module coupled to at least one of the database or the processor. The database includes a plurality of records, at least one record of the plurality including at least one tissue treatment parameter and a level of erythema associated with the at least one treatment parameter. The control module is configured to control an energy delivery parameter responsive to a measurement of erythema.  
       [0031] Another embodiment provides a method for treating tissue using visual or photographic documentation or data. Pre-treatment photographs or images can be made of a selected treatment site using photographic or video imaging means and stored digitally or in analog form. Then an energy delivery treatment can be performed to obtain a desired tissue effect such as tissue reshaping, remodeling, smoothing tightening or rejuvenation. A post treatment image can then be made and anatomical landmarks utilized to align the post-treatment and pre-treatment images manually or using computational means. A comparison can then be made between the pre and post treatments to qualitatively and/or quantitatively determine the effect of a given treatment session and/or a treatment endpoint. The comparison can be done using projection means, magnification means or electronic image analysis means such as an image analysis or spatial analysis software module. The comparison and/or alignment can also be made utilizing a grid pattern drawn or superimposed onto the treatment site using computation means. Subsequent energy delivery treatments can be performed if needed and controlled utilizing information derived from the comparison until the desired tissue effect or endpoint is obtained. 
     
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
     [0032]FIG. 1 is a lateral view of an embodiment of a skin treatment apparatus illustrating components of the apparatus including a feedback control system.  
     [0033]FIG. 2 a  is a lateral perspective view of the apparatus of FIG. 1 illustrating the introducer, template and energy delivery device.  
     [0034]FIG. 2 b  is a lateral perspective view of the apparatus of FIG. 1 illustrating the use of a fluid delivery device.  
     [0035]FIG. 3 illustrates intramolecular cross-linking of collagen.  
     [0036]FIG. 4 illustrates intermolecular cross-linking of collagen.  
     [0037]FIGS. 5 and 6 are two graphs illustrating the probability of collagen cleavage as a function of molecular bond strength at 37° C.  
     [0038]FIG. 7 is a top view of a skin surface, illustrating the peaks and valleys of the surface and the force components applied to the surface resulting from the application of a mechanical force.  
     [0039]FIG. 8 is a cross-sectional view of the skin surface illustrated in FIG. 7.  
     [0040]FIG. 9 is a cut-away view of the skin surface, with troughs and ridges, and underlying subcutaneous soft tissue.  
     [0041]FIG. 10( a ) is a lateral perspective view of a telescoping segment of a breast expander useful with the apparatus of FIG. 1.  
     [0042]FIG. 10( b ) is a front perspective view of the breast expander of FIG. 10( a ).  
     [0043]FIG. 10( c ) illustrates a bra which functions as the template of FIG. 1.  
     [0044]FIG. 10( d ) is a lateral cross-sectional perspective view of a partially expanded breast expander within a breast.  
     [0045]FIG. 10( e ) is a lateral cross-sectional perspective view of a fully expanded breast expander within a breast.  
     [0046]FIG. 11 illustrates a template in the form of a garment.  
     [0047]FIG. 12( a ) illustrates a template that is positioned over a nose.  
     [0048]FIG. 12( b ) illustrates a template that is positioned over an ear.  
     [0049]FIG. 13 is a perspective view of a template that is useful in treating the cervix.  
     [0050]FIG. 14 is a cross-sectional view of the template of FIG. 13.  
     [0051]FIG. 15( a ) is a front view of an orthodontic appliance that includes RF electrodes.  
     [0052]FIG. 15( b ) is perspective view of an orthodontic appliance template of the device of FIG. 1.  
     [0053]FIG. 15( c ) is cross-sectional view of the template of FIG. 15( b ).  
     [0054]FIG. 16 is a perspective view illustrating a template made of a semisolid material that becomes more conforming to underlying soft tissue upon the application of a mechanical force.  
     [0055]FIG. 17 illustrates a template with an adherent or suction mechanical force delivery surface that permits manual manipulation of skin and soft tissue structures.  
     [0056]FIG. 18 a  is a schematic diagram illustrating a monopolar RF energy system including the use of a ground pad electrode.  
     [0057]FIG. 18 b  is a schematic diagram illustrating a bipolar RF energy system and bipolar RF energy electrode.  
     [0058]FIGS. 19 a  and  19   b  are later views illustrating geometric embodiments of an RF electrode configured to reduce edge effects.  
     [0059]FIG. 20 a  is a lateral view illustrating the use of conforming layers with an RF electrode configured to reduce edge effects.  
     [0060]FIG. 20 b  is a lateral view illustrating the use of semiconductive material template with an RF electrode configured to reduce edge effects.  
     [0061]FIG. 21 is a lateral view illustrating the use of template with a conformable surface.  
     [0062]FIG. 22 is a schematic diagram illustrating the use of a monitoring system to monitor stray current from the active or the passive electrode.  
     [0063]FIG. 23 depicts a block diagram of the feed back control system that can be used with the pelvic treatment apparatus.  
     [0064]FIG. 24 depicts a block diagram of an analog amplifier, analog multiplexer and microprocessor used with the feedback control system of FIG. 23.  
     [0065]FIG. 25 depicts a block diagram of the operations performed in the feedback control system depicted in FIG. 23.  
     [0066]FIG. 26 is a schematic diagram illustrating an embodiment for using patient feedback during tissue treatment.  
     [0067]FIG. 27 is a schematic diagram illustrating the use of correlations between biometric signals and a patient determined scale of thermal/pain sensation feedback.  
     [0068]FIG. 28 is a schematic diagram illustrating an embodiment for using biometric feedback signals (from the same or different locations on the body) to determine patient pain or thermal sensation resulting from a tissue treatment.  
     [0069]FIG. 29 a  is a schematic diagram illustrating an embodiment for using a patient determined scale of pain or thermal sensation as well a model or database to calibrate and/or correlate the scale.  
     [0070]FIG. 29 b  is a block diagram illustrating a configuration of a database used in an embodiment of the invention.  
     [0071]FIG. 29 c  illustrates an embodiment of a database table or an object table.  
     [0072]FIG. 30 is a flow chart illustrating a tissue treatment algorithm with patient feedback using a topical anesthetic.  
     [0073]FIG. 31 is a flow chart illustrating a tissue treatment algorithm with patient feedback using an injected local anesthetic.  
     [0074]FIG. 32 is a flow chart illustrating a photographic/visual documentation algorithm that can be used in one or more embodiments of the invention.  
     [0075]FIGS. 33 a - 33   b  are lateral views illustrating alignment and/or superimposition of pre and post images of the tissue site and surrounding tissue.  
     [0076]FIG. 34 is a lateral view illustrating use of a grid pattern aligned with a selected tissue feature or axis in an embodiment of a method to correct an aesthetic deformity. 
    
    
     DETAILED DESCRIPTION  
     [0077] Embodiments of the invention provide a method and apparatus to deliver energy to modify tissue including, collagen containing tissue, in the epidermal, dermal and subcutaneous tissue layers including adipose tissue. The energy can include electromagnetic, optical, thermal, acoustic and mechanical energy and combinations thereof. The modification of tissue can include modifying a physical feature of the tissue, a structure of the tissue or a physical property of the tissue and combinations thereof. The modification can be achieved by delivering sufficient energy to cause collagen shrinkage, and/or a wound healing response including the deposition of new or nascent collagen. For embodiments using topical energy delivery, energy can be delivered coupled with topical cooling to achieve heating of the subjacent dermis while preserving the epidermis. This provides a means to tighten or otherwise rejuvenate skin via two mechanisms. First an initial molecular contraction of pre-existing dermal collagen immediately tightens the skin during treatment. Then after 2 to 3 weeks, a secondary wound healing response further tightens skin from a cellular based contraction of dermal fibroblasts  
     [0078] In various embodiments of the invention, the tissue modification procedure can be performed using patient feedback to control one or more aspects of the procedure including, without limitation, the delivery of energy to the tissue site, the delivery of a cooling medium to the tissue site and the level of thermal injury to the tissue site. Also, embodiments of the invention can be configured to use feedback to perform one or more of the following (i) reduce patient pain and discomfort before during or after a tissue treatment procedure; (ii) reduce the incidence of unwanted tissue injury including thermal injury, burns, blistering, and the like to selected tissue, tissue layers or tissue structures; (iii) increase the delivery of energy to a target tissue site or the temperature of the site with reduced injury to non target tissue; (iv) reduce procedure time; and (v) provide a more uniform therapeutic pattern of energy delivery over all or a portion of the treatment area that will at least partially increase skin tightening. Forms of patient feedback that can be utilized include without limitation verbal feedback, biometric feedback, manual feedback and combinations thereof.  
     [0079] Biometric feedback can include without limitation, temperature measurement (on one or more sites on the body), EGK, EEG, blood pressure, pulse rate, respirations rate, electromyograms, skin electro-conductivity, other physiological measurements, voice stress recognition and combinations thereof. The biometric measurements can be made using on or more sensors described herein or known in the biomedical engineering, physiology or medical instrument arts. Manual feedback can be signaled by a variety of means known in the art including use of a keyboard, handgrip with pressure/force sensors, hand held device having a knob (coupled to a rheostat), switch, rocker switch, other hand or foot actuated device or other input/output device known in the art. The pressure or forces sensors can include solid-state sensors such as silicon strain gauges and MEM (micro electronic machines) and/or nanotechnology devices known in the art. Examples of MEMS devices include those manufactured by the Motorola® Corporation. Verbal feedback can include pain levels communicated to the physician as well as stress levels in the patient&#39;s voice determined by speech or pattern recognition software  
     [0080] A discussion will now be presented of the use of various treatment apparatuses, energy devices, power sources, cooling devices, sensors and tissue treatment procedures which may be utilized with one or more embodiments of the invention. An exemplary embodiment of an apparatus  8  to treat or modify tissue  9  utilizing one or more methods of patient feedback described herein is shown in FIG. 1. This apparatus is exemplary and other tissue treatment apparatuses and methods are equally applicable. An example of an alternative apparatus can include one or more dermatological lasers known in the art. Other alternatives can include use of heat lamps, ultrasound or heat transfer fluids.  
     [0081] Tissue  9  can include a surface tissue layer  9 ′ and underlying tissue  9 ″. Surface tissue  9 ′ can include the skin, epidermal skin layer or any collagen containing tissue and underlying tissue  9 ″ can include dermal and sub-dermal layers including collagen containing underlying tissue.  
     [0082] In various embodiments, apparatus  8  can be configured to have one or more of the following components or functions: i) feedback control of energy delivery and applied force and other parameters discussed herein ii) cooled energy delivery devices, iii) delivery of cooling fluid to tissue site and/or energy devices iv) contact sensing of electrodes, v) control of energy delivery and applied force via the use of a database of combinations of energy, force, pressure, etc including direction, rates and total amounts delivered over time, the data base can alone or in combination with feedback control.  
     [0083] Referring now to FIGS. 1, 2 a  and  2   b , apparatus  10  can include an introducer  10  with proximal and distal ends  10 ′ and  10 ″. Introducer  10  is coupled at its distal end  10 ″ to a template  12  which in turn can include a soft tissue mechanical force application surface  14  and a receiving opening  16  to receive a body structure. Mechanical force application surface  14  is configured to receive the body structure and apply force to soft tissue in the body structure, resulting in the application of a force  17  to that structure including its surface and underlying tissue.  
     [0084] Introducer  10  may have one or more lumens  13 ′ that extend the full length of the introducer or only a portion thereof. These lumens may be used as paths for the delivery of fluids and gases, as well as providing channels for cables, catheters, guide wires, pull wires, insulated wires, optical fibers, and viewing devices/scopes. In one embodiment, the introducer can be a multilumen catheter, as is well known to those skilled in the art. In another embodiment, introducer  10  can include or otherwise be coupled to a viewing device such as an endoscope, viewing scopes and the like.  
     [0085] In various embodiments, apparatus  8  can include a handpiece  11  coupled to introducer  10 . Handpiece  11  can include a deflection mechanism  11 ′ such as a pull wire or other mechanism known in the art. Deflection mechanism  11 ′ can be used to deflect the distal end  10 ″ of introducer  10  including template  12  by an angle  10 ′″ relative to a lateral axis  10 ″″ of introducer  10 . In various embodiments angle  10 ′″ can be an acute angle (e.g.&lt;90°) with specific embodiments of 60, 45 or 30°.  
     [0086] An energy delivery device  18  is coupled to template  12 . Energy delivery device  18  is configured to deliver energy to template  12  to form a template energy delivery surface  20  at an interior of template  12 . Energy delivery surface  20  contacts the skin or other tissue at a tissue interface  21 . In various embodiments, one or more energy delivery devices  18  may deliver energy to template  12  and energy delivery surface  20 . An energy source  22  (described herein) is coupled to energy delivery device  18  and/or energy delivery surface  20 . Energy delivery device  18  and energy source  22  may be a single integral unit or each can be separate.  
     [0087] Referring now to FIG. 2 b , a fluid delivery device  13  can be coupled to introducer  10  and/or template  12  including energy delivery device  18 . Fluid delivery device  13  (which can also be a cooling device  13 ) serves to deliver fluid to tissue interface  21  and surrounding tissue to prevent or otherwise reduce thermal damage of the skin surface with the topical application of energy. Fluid delivery device  13  can be configured to be controlled by or responsive to various embodiments of patient feedback described herein. In an embodiment, fluid delivery device  13  can be configured (via means of a processor with embedded programming or electronic algorithm) to delivery an amount of fluid or cooling proportional to patient indicated level of pain or thermal sensation.  
     [0088] In various embodiments, fluid delivery device  13  can include one or more lumens  13 ′ which can be the same or otherwise continuous (e.g. fluidically coupled) with lumen  13 ′ in introducer  10  and template  12 . Lumens  13 ′ can be fluidically coupled to a pressure source  13 ″ and fluid reservoir  13 ′″. Fluid delivery device  13  can also be coupled to a control system described herein. In various embodiments, pressure source  13 ″ can be a pump (such as a peristaltic pump) or a tank or other source of pressurized inert gas (e.g. nitrogen, helium and the like).  
     [0089] Fluid delivery device  13  can be configured to deliver a heat transfer media  15  (also called a cooling media  15 , flowable media  15  or fluid  15 ) to tissue interface  21 , that serves to dissipate sufficient heat from the skin and underlying tissue at or near tissue interface  21  during the delivery of energy at or near this site so as to prevent or reduce thermal damage including burning and blistering. Similarly, fluid delivery device  13  may also deliver fluid  15  to and dissipate heat from energy delivery device  18  and/or template  12  to achieve a similar result. In various embodiments, introducer  10 , including lumens  13 ′ can serve as a cooling media introduction member  10  for heat transfer media  15 .  
     [0090] Fluid  15  can serve as a heat transfer medium and its composition and physical properties can be configured to optimize its ability to dissipate heat. Desirable physical properties of fluid  15  include, but are not limited to, a high heat capacity (e.g. specific heat) and a high thermal conductivity (e.g. conduction coefficient) both of which can be comparable to liquid water in various embodiments or enhanced by the addition of chemical additives known in the art. In other embodiments, fluid  15  may also serve to conduct RF energy and therefore have good electrical conductivity. Fluid  15  can be selected from a variety of fluids including, but not limited to water, saline solution (or other salt aqueous salt solutions), alcohol (ethyl or methyl), ethylene glycol or a combination thereof. Also, fluid  15  can be in a liquid or gaseous state, or may exist in two or more phases and may undergo a phase change as part of its cooling function, such as melting or evaporation (whereby heat is absorbed by the fluid as a latent heat of fusion or evaporation). In a specific embodiment, fluid  15  can be a liquid at or near its saturation temperature. In another embodiment, fluid  15  can be a gas which undergoes a rapid expansion resulting in a joule Thompson cooling of one or more of the following: fluid  15 , tissue interface  21 , energy delivery device  18  and energy delivery surface  20 . In various embodiments, fluid  15  can be cooled to over a range of temperatures including but not limited to 32 to 98° F. In other embodiments fluid  15  can be configured to be cooled to cryogenic temperatures in a range including but not limited to 32 to −100° F. Fluid or heat transfer media  15  can be cooled by a variety of mechanisms, including but not limited to, conductive cooling, convective cooling (force and unforced), radiative cooling, evaporative cooling, melt cooling and ebullient cooling. Ebullient cooling involves the use of a liquid heat transfer liquid at or near saturation temperature. In various embodiments fluid  15  can also be an electrolytic fluid used to conduct or deliver RF energy to or in tissue and/or reduce impedance of selected tissue. Suitable electrolytic solutions can include without limitation, saline solutions, phosphate buffered saline solution, 0.9% saline solution, hypertonic saline solution, hypotonic saline solution, saline carrier solutions carrying a medicament, lidocain solutions, conductive gels known in the art, saline containing gels and combinations thereof.  
     [0091] In other embodiments, thermal damage to skin  9 ′ and underlying tissue  9 ″ can be reduced or prevented through the use of a reverse thermal gradient device  25 . Reverse thermal gradient device  25  can be positioned at or thermally coupled to template  12 , mechanical force application surface  14  or energy delivery device  18 . Suitable reverse thermal gradient devices  25  include but are not limited to peltier effect devices known in the art. Gradient device  25  can be configured to be responsive to or controlled by various embodiments of patient feedback described herein. In an embodiment, gradient device  25  can be configured (via means of a processor with embedded programming or electronic algorithms) to delivery an amount of fluid or cooling proportional to patient indicated level of pain or thermal sensation or to biometric indications thereof.  
     [0092] The delivery of cooling fluid  15  by fluid delivery device  13 , energy (e.g. heat) by energy delivery device  18  and force (e.g. pressure) by force applications surface  14  can be regulated separately or in combination by a feedback control system described herein. Inputs parameters to the feedback control system  54  can include, but are not limited to temperature, impedance, pain or thermal sensation and biometric indications thereof, skin conductivity, skin color, and pressure of the tissue interface  21 , energy delivery device  18  (including surface  18 ′) and underlying structure, separately or in combination. The sequence of cooling and heating delivered to tissue interface  21  is controllable to prevent or reduce burning and other thermal damage to tissue.  
     [0093] Different cooling and heating control algorithms can be employed in different combinations of continuous and discontinuous modes of heating and cooling application. These control algorithms can be configured to receive input from one or more embodiments of patient feedback described herein as well as a database described herein of energy delivery parameters or other treatment parameters correlated to pain or thermal sensation levels or biometric indications thereof. Specific control algorithms that can be employed methods of patient feedback and control systems described herein include proportional (P), proportional-integral (PI) and proportional-integral-derivative algorithms (PID) the like, all well known in the art. These algorithms can use one or more input variables described herein including patient feedback and have their proportional, integral and derivative gains tuned to the specific combination of input variables. The control algorithms can be run either in an analog or digital mode using hardware described herein and can be configured to be coupled to one or more databases described herein. Temporal modes of delivery of cooling and energy to tissue interface  21  include, but are not limited to fixed rate continuous, variable rate continuous, fixed rate pulsed, variable rate pulsed and variable amount pulsing. Example delivery modes include the continuous application of the cooling means in which the flow rate is varied and application of the power source is pulsed or continuous i.e., the application of power can be applied in a pulsed fashion with continuous cooling in which the flow rate of cooling solution and the rate of RF energy pulsing (at a set power level) is varied as a function of surface monitoring of tissue interface  21 . Pulsing of the cooling medium  15  flow rate may be either a constant or variable rate. A pulsed or intermittent application of cooling in which the frequency of pulsing is determined by surface monitors or patient feedback can also be combined with the application of a continuous or pulsed energy source. For instance, cooling can be applied as an intermittent spraying of a cryogen solution with a continuous application of RF energy. Even the amount of a single pulse of the cooling medium can be varied. Any liquid, such as a cryogen (e.g. liquid nitrogen) that quickly evaporates with heat, can be applied in this fashion. Another example of variable pulsing is the application of a constant rate of RF pulsing at a variable power level that is feedback controlled. Cooling can also be varied by pulsing the flow rate of continuous cooling. More complicated algorithms can include the use of variable sequences of both cooling and heating. Less complicated algorithms can include a variable component with a fixed component of heating or cooling. An example of a less complicated algorithm involves the use of a database in which the algorithm may not use feedback control and in which certain fixed or non variable combinations of heating and cooling are allowed to initiate a treatment cycle. Other embodiments of procedure control algorithms can use a combination of input from a database as well as feedback control.  
     [0094] Template  12  can be configured to deliver both electromagnetic energy and mechanical force to the selected tissue or anatomical structure  9 . Suitable anatomical structures  9  include, but are not limited to, hips, buttocks, thighs, calves, knees, angles, feet, perineum, the abdomen, chest, back flanks, waistline, legs, arms, legs, arms, wrists, upper arms, axilla, elbows, eyelids, face, neck, ears, nose, lips, checks, forehead, hands, breasts and the like. In various embodiments, tissue structure  9  includes any collagen containing tissue structure.  
     [0095] Mechanical force application surface  14  can apply pressure, suction, adhesive forces and the like in order to create an extension or compression of the soft tissue structure and/or the skin surface. In an embodiment, the resting skin tension of the treatment site can be altered to direct a force vector of skin tightening through physical manipulation of the skin. Manually accentuating a skin redundancy along the longitudinal axis of the treatment grid will reduce the resting skin tension of the treatment site in the preferred direction and thereby further assist skin tightening in the preferred direction. One or more energy delivery devices  18  can form an energy delivery surface  20  in template  12 . In various embodiments, energy delivery surface  20  can be the same size as force application surface  14  or it can be a smaller area.  
     [0096] A variety of mechanical forces can be applied to tissue using apparatus  8  and force application surface  14 , including but not limited to, the following: (i) pressure, (ii) expansion, (iii) stretching, (iv) extension, (v) prolongation, or (vi) lengthening. The amount, direction and type of force can be controlled or titrated using one or more forms of patient feedback. For example the amount of force can be decreased in response to threshold pain indication by the patient.  
     [0097] The pressure force can be a positive pressure or a negative pressure. Positive pressure provides a compression of collagen containing tissue, with converging and diverging force vectors, while negative pressure creates an extension of collagen containing tissue with converging and diverging vectors. In various embodiments, the force  17  applied by force application surface  14  to tissue interface  21  is monitored and used as an input parameter (by sensors  23  described herein) as well as feedback controlled (by means described herein) so as to perform or facilitate one or more of the following functions: (i) minimize and/or prevent burning and other thermal tissue damage; (ii) serve as a therapeutic modality to increase or decrease the delivery of thermal energy and mechanical force to the intended treatment site. In a preferred embodiment, the applied force  17  measured and monitored as described, is a pressure (e.g. force per unit tissue surface area) or otherwise expressed as such. In bipolar electrode applications describe herein, the force  17  applied by force application surface  14  can be limited to that amount necessary to achieve contact with skin.  
     [0098] Suitable sensors  23  that can that can be used to measure applied force or pressure to tissue include, but are not limited to strain gauges which can be made out of silicon and micro machined using techniques well known in the art. Suitable pressure sensors include the NPH series TO-8 Packaged Silicon Pressure Sensor manufactured by Lucas NovaSensor®.  
     [0099] Suitable energy sources  22  that may be employed in one or more embodiments of the invention include, but are not limited to, the following: (i) a radio-frequency (RF) source coupled to an RF electrode, (ii) a coherent source of light coupled to an optical fiber, (iii) an incoherent light source coupled to an optical fiber, (iv) a heated fluid coupled to a catheter with a closed channel configured to receive the heated fluid, (v) a heated fluid coupled to a catheter with an open channel configured to receive the heated fluid, (vi) a cooled fluid coupled to a catheter with a closed channel configured to receive the cooled fluid, (vii) a cooled fluid coupled to a catheter with an open channel configured to receive the cooled fluid, (viii) a cryogenic fluid, (ix) a resistive heating source, (x) a microwave source providing energy from 915 MHz to 2.45 GHz and coupled to a microwave antenna, (xi) an ultrasound power source coupled to an ultrasound emitter, wherein the ultrasound power source produces energy in the range of 300 KHZ to 3 GHz, (xii) a microwave source or (xiii) a fluid jet.  
     [0100] Energy delivery  18  can be configured to be controlled by or responsive to various embodiments of patient feedback described herein. In an embodiment, the energy delivery device can be configured (via a control system  54  described herein) to deliver an amount of energy responsive to a patient indicated level of pain or thermal sensation, a biometric signal correlated to or otherwise indicative of pain or thermal sensation. In various embodiments using patient feedback, energy delivery device  18  can be configured to operate within one or more of the following parameters: (i) provide a controlled delivery of electromagnetic energy to the skin surface that does not exceed, 1,000 joules/cm2, or 10 joules/sec/cm2; (ii) provide a controlled delivery of electromagnetic energy to the skin surface not exceeding 600 joules/cm2 during a single treatment session (during a twenty-four hour period); (iii) provide a controlled delivery of electromagnetic energy to the skin surface not exceeding 200 joules/cm2 during a single treatment session, or not exceeding 10 joules/sec/cm2; (iv) operate in an impedance range at the skin surface of, 70 ohms cm2 (measured at a frequency of 88 Hz) to 40 Kohms cm2 (measured at a frequency of 10 KHz); (v) provides a controlled delivery of electromagnetic energy to operate in a range of skin thermal conductivities (at or near the skin surface) of 0.20 to 1.2 k (where k=1*[W/(m. C.°)]); and (vi) operate in a range of compression forces applied to the skin surface and/or the underlying soft tissue anatomical structure not exceeding 400 mmHg, not exceeding 300 mm, not exceeding 200 mmHg or not exceeding 100 mmHg. In an embodiment a database, described herein, can be developed that correlates one or more of these parameters to an associated level of pain or thermal sensation or a biometric indication thereof. The database can subsequently be configured to be utilized to control or regulate one of these parameters during an energy delivery procedure through the use of patient feedback which is indicative of pain or thermal sensation.  
     [0101] For ease of discussion, the power source utilized is an RF source and energy delivery device  18  is one or more RF electrodes  18  also described as electrodes  18  having a surface  18 ′. However, all of the other power sources and energy delivery devices mentioned herein are equally applicable to apparatus  8  and embodiments of methods using apparatus  8  including various embodiments using patient feedback described herein.  
     [0102] Template  12  can apply both a mechanical force and deliver energy to do one or more of the following: (i) tighten the skin, (ii) smooth the surface of the skin, (iii) improve a compliance of the skin surface, (iv) improve a flexibility of the skin surface; and (v) provides cellular remodeling of collagen in soft tissue anatomical structures. Mechanical force application surface  14 , (i) is at least partially conforming to the skin surface, (ii) may apply a substantially even pressure to the soft tissue anatomical structures and (iii) can apply a variable pressure to the skin surface and underlying soft tissue structures. The combined delivery of electromagnetic energy and a mechanical force is used to create a three-dimensional contouring of the soft tissue structure. The amount of mechanical force applied by mechanical force application surface  14  can be selectable to meet one or more of the following criteria: (i) sufficient to achieve a smoothing effect of the skin surface, (ii) can be less than the tensile strength of collagen in tissue and (iii) sufficient to create force vectors that cleave collagen cross-links to remodel collagen containing structures.  
     [0103] A sensor  23  is positioned at or adjacent energy delivery surface  20  and/or electrode  18  to monitor temperature, impedance (electrical), cooling media fluid flow and the like of tissue  9  of one or more of the following: tissue interface  21 , tissue  11 , or electrode  18 . Suitable sensors  23  include impedance, thermal and flow measurement devices. Sensor  23  is used to control the delivery of energy and reduce the risk of cell necrosis at the surface of the skin as well and/or damage to underlying soft tissue structures. Sensor  23  is of conventional design, including but not limited to thermistors, thermocouples, resistive wires, and the like. A suitable thermal sensor  23  includes a T type thermocouple with copper constantene, J type, E type, K type, fiber optics, resistive wires, thermocouple IR detectors, and the like. Suitable flow sensors include ultrasonic, electromagnetic and aneometric (including thin and hot film varieties) as is well known in the art. In various embodiments, two or more temperature and impedance sensors  23  are placed on opposite sides or otherwise opposing geometric positions of electrode  18  or energy delivery surface  20 .  
     [0104] Apparatus  8  can be configured to deliver sufficient energy and/or force to meet the energy levels for disrupting and/or cleaving each type of molecular bond within the collagen matrix. Patient feedback can be utilized to regulate delivered energy level for disrupting/cleaving each type of molecular bond. Collagen crosslinks may be either intramolecular (hydrogen bond) or intermolecular (covalent and ionic bonds). Hydrogen bonds are disrupted by heat. Covalent bonds may be cleaved with the stress created from the hydrogen bond disruption and the application of an external mechanical force. Cleavage of ionic bonds may be achieved with an alternating electromagnetic force (as would be induced by an electromagnetic field such as an RF field) in addition to the application of an external mechanical force that is applied by template  12 . The strength of a hydrogen bond is relatively weak and can be thermally disrupted without ablation of tissue. The in vitro thermal cleavage of the hydrogen bond crosslinks of tropocollagen can result in the molecular contraction of the triple helix up to one third of its original length. However, in vivo collagen exists in fibrils that have extensive intermolecular crosslinks that are covalent or ionic in nature. These covalent and ionic crosslinks are stronger and cannot be easily disrupted with heat alone. These intermolecular bonds are the main structural determinants of the collagen matrix strength and morphology. In vivo thermal disruption of intramolecular hydrogen bonds will not by itself result in a significant change in matrix morphology. As the intermolecular crosslinks are heat stable, cleavage may occur by a secondary process which can be the result of thermal disruption of intramolecular hydrogen bonds. In the non-polar region of the collagen fibril, intermolecular covalent bonds predominate (intramolecular covalent bonds are also present but are fewer in number).  
     [0105] These intermolecular covalent crosslinks increase with age, (refer to FIGS. 3 and 4). As a result, the solubility of the collagen matrix in a soft tissue structure is reduced with this maturation process. Although tensile strength is increased, the collagen containing tissue becomes less compliant. Cleavage of an intermolecular bond can require approximately one ev (electron volt) of energy and cannot be accomplished by heat without thermal ablation of tissue. In addition, covalent bonds are not strongly polar and will not be significantly affected by an RF current at this reduced power level. Cleavage of intermolecular covalent bonds that result in matrix remodeling without ablation is achieved by the stress created from the thermal disruption of intramolecular hydrogen bonds. Additional remodeling stress can be provided with the application of an external force that has the appropriate orientation to the fibrils of the matrix. Suitable orientations include approximately parallel to the lateral axis of the collagen fibrils. Ionic bonds are essentially intermolecular and are present in the polar regions of the fibril. Although slightly weaker than covalent bonds, thermal disruption of ionic bonds cannot occur without ablation of tissue. An RF field is an effective means to cleave these bonds and can be created by the in phase alternating ionic motion of the extracellular fluid. Frequency modulation of the RF current may allow coupling to the ionic bonds in the polar regions of the fibril. Remodeling of a target site may be optimized by the selection of a band of the spectrum that is target site specific in order to reduce collateral damage. If an optimized intrinsic absorption is insufficient then a selective medium may be provided to alter the absorption in order to discriminate various soft tissue structures. This may be achieved by altering the absorption. By altering the extra-cellular fluid content of a soft tissue in specific ways, the delivery of energy to a target tissue site is achieved with minimal damage to collateral structures such as skin and adjacent soft tissue structures.  
     [0106] The reforming of bonds at the same bond site can diminish the remodeling process. Relaxation phenomena may inhibited with the application of an external mechanical force that separates bond sites but allows the reforming of these covalent and ionic bonds in a lengthened or contracted morphology. This can be the underlying biophysical process that occurs with the controlled remodeling of the collagen matrix. Ground substance may also function to diminish relaxation of crosslinks through competitive inhibition. Chondroitin sulfate is a highly charged molecule that is attached to a protein in a “bottle brush” configuration. This configuration promotes attachment at polar regions of the fibril and reduces the relaxation of ionic bonds in this region. As a consequence, immature soluble collagen, which has fewer intermolecular crosslinks and contains a higher concentration of ground substance, may be more easily remodeled. The induction of scar collagen through the wound healing sequence may also facilitate the remodeling process within a treatment area.  
     [0107] Collagen cleavage in tissue is a probability event dependant on temperature. There is a greater probability that a collagen bond will be cleaved with higher temperatures. Cleavage of collagen bonds will occur at lower temperatures but at a lower frequency. Low level thermal cleavage is frequently associated with relaxation phenomena in which there is not a net change in molecular length. An external force that mechanically cleaves the fibril may reduce the probability of relaxation phenomena. The application of an external force will also provide a means to lengthen or contract the collagen matrix at lower temperatures while reducing the potential of surface ablation. The cleavage of crosslinks with collagen remodeling may be occurring at a basal metabolic temperature that is expressed morphologically as the process of aging. Although the probability for significant cleavage in a short period of time is small, aging may be expressed as a low level steady state of collagen remodeling with the external force of gravity that becomes very significant over a period of decades. Hydrogen bonds that are relatively weak (e.g. bond strength of 0.2 to 0.4 ev) are formed within the tertiary structure of the tropocollagen molecule.  
     [0108] Thermal disruption of these bonds can be achieved without ablation of tissue or cell necrosis. The probability of hydrogen bond disruption at a certain temperature can be predicted by statistical thermodynamics. If a Boltzmann distribution is used to calculate the probability of bond disruption then a graph illustrating the relationship between bond strength and the probability of bond disruption at a certain temperature can be produced. Graphs of the probability of cleavage (at 37° C.) versus bond strengths are shown in FIGS. 5 and 6.  
     [0109] Different morphological expressions of aging may be due to the effect of gravity upon the matrix of a particular area. In areas of the skin envelope in which gravity lengthens the matrix, elastosis of skin will occur. In contrast to skin aging certain anatomical structures, such as joint ligaments, will appear to tighten with the aging process. The reduced range of motion may be due in part to the vertical vector of gravity contracting the matrix of a vertically aligned ligament. However, most of the “tightening” or reduced range of motion of joints may not be secondary to a contracted matrix but is due to reduced flexibility of the matrix caused by increased intramolecular cross-linking that occurs with aging. Essentially, the controlled remodeling of collagen is the reversal of the aging process and involves the reduction in the number of intermolecular crosslinks. As a result the remodeled matrix becomes less brittle. Greater flexibility of the soft tissue has several functional advantages including an increased range of motion of component joints.  
     [0110] When the rate of thermal cleavage of intramolecular crosslinks exceeds the rate of relaxation (reforming of hydrogen bonds) then the contraction of the tertiary structure of the molecule can be achieved. No external force is required for this process to occur. Essentially, the contraction of the tertiary structure of the molecule creates the initial intermolecular vector of contraction. The application of an external mechanical force during thermal cleavage will also affect the length of the collagen fibril and is determined by the overall sum of intrinsic and extrinsic vectors that is applied during a cleavage event. Collagen fibrils in a matrix exhibit a variety of spatial orientations. The matrix is lengthened if the sum of all vectors act to distract the fibril. Contraction of the matrix is facilitated if the sum of all extrinsic vectors acts to shorten the fibril. Thermal disruption of intramolecular bonds and mechanical cleavage of intermolecular crosslinks is also affected by relaxation events that restore preexisting configurations. However, a permanent change of molecular length will occur if crosslinks are reformed after lengthening or contraction of the collagen fibril. The continuous application of an external mechanical force will increase the probability of crosslinks forming, alter lengthening or contraction of the fibril.  
     [0111] The amount of (intramolecular) hydrogen bond cleavage required for remodeling can be determined by the combined ionic and covalent intermolecular bond strengths within the collagen fibril. Until this threshold is reached little or no change in the quaternary structure of the collagen fibril will occur. When the intermolecular stress is adequate, cleavage of the ionic and covalent bonds will occur. Typically, the intermolecular cleavage of ionic and covalent bonds will occur with a ratcheting effect from the realignment of polar and non-polar regions in the lengthened or contracted fibril. The birefringence (as seen with the electron microscope) of the collagen fibril may be altered but not lost with this remodeling process. The quarter staggered configuration of the tropocollagen molecules in the native fiber exhibits a 680 D banding which either lengthens or contracts depending on the clinical application. The application of the mechanical force with template  12  during the remodeling process determines if a lengthened or contracted morphology of the collagen fibril is created. An external force of contraction will result in the contraction of the tertiary and quaternary structure of the matrix. With the application of an external distraction force, intramolecular contraction may still occur from the intrinsic vector that is inherent within its tertiary structure. However, overall lengthening of the quaternary structure of the fibril will occur due to the mechanical cleavage of the intermolecular bonds. Contraction of the tertiary structure with overall lengthening of the collagen fibril can alter the birefringence of the matrix. The altered periodicity will be exhibited in the remodeled matrix that will correlate to the amount of lengthening achieved.  
     [0112] Delivery of both electromagnetic energy and mechanical energy to the selected body structure involves both molecular and cellular remodeling of collagen containing tissues. In an embodiment, low-level thermal treatments can be delivered over several days to provide an alternative way to contract skin with minimal blistering and cell necrosis. Patient feedback can be utilized using the pain/thermal scale to maintain thermal treatment at low levels. For example, a series of treatments can be delivered where the energy level is titrated to maintain pain perception at or below a level 1.  
     [0113] Cellular contraction involves the initiation of an inflammatory/wound healing sequence that is perpetuated over several weeks with sequential and lengthy low level thermal treatments. Contraction of skin is achieved through fibroblastic multiplication and contraction with the deposition of a static supporting matrix of nascent scar collagen. This cellular contraction process is a biological threshold event initiated by the degranulation of the mast cell that releases histamine. This histamine release initiates the inflammatory wound healing sequence.  
     [0114] Molecular contraction of collagen is a more immediate biophysical process that occurs most efficiently with electromagnetic energy delivery devices, including but not limited to RF electrodes. The clinical setting is physician controlled and can involve more precise temperature, impedance, cooling media flow and energy delivery monitoring to avoid blistering of the skin. Measured impedance will vary with the frequency of the electromagnetic energy applied to the skin surface and/or underlying soft tissue structure.  
     [0115] Patients may be treated with one or more modalities described herein to achieve a selectable esthetic result. Refinements to the treatment area may be performed using apparatus  8  in the physician&#39;s office. However, tightening of a skin surface may accentuate any preexisting contour irregularities. For this reason, conforming esthetic template  12  can also be configured to be used to smooth surface contour irregularities. The application of a mechanical force upon the collagen matrix can involve both contraction or distraction of the selected soft tissue structure to achieve a smoother contour. Thermal (or electromagnetic) cleavage of collagen crosslinks when combined with a mechanical force creates force vectors that contract, distract or shear the longitudinal axis of the fibril. A vector space is created with the combination of a scalar component (heat) and a force vector (an externally applied mechanical force). The force vectors within this vector space may vary depending upon the specific morphology of the tissue. For example, the peaks and valleys of cellulite will have different force vectors when uniform external compression is applied. As illustrated in FIGS. 7 and 8, template  12  produces converging and diverging force vectors that act to smooth surface morphology by contracting (valleys) and distracting (peaks) the collagen matrix in a soft tissue structure. Diverging vectors on the peaks lengthen the collagen matrix while converging vectors in the valleys contract and compact the collagen matrix. The overall result is the smoothing of an irregular skin surface.  
     [0116] Apparatus  8  may also be used to treat wrinkling of the skin. The treatment of skin wrinkles is shown in FIG. 9. In a skin wrinkle the vectors of applied force can be directed perpendicular to the troughs and ridges of this contour deformity. Diverging vectors at the ridges of the skin converge in the trough of the wrinkle to smooth the surface morphology. The collagen matrix can be distracted or extended at the ridges and contracted in the valleys. One or embodiments of patient feedback can be utilized to optimize this process by controlling energy to minimize blistering or burning. The overall result is the smoothing of the wrinkled skin surface.  
     [0117] Linear scars exhibit a similar morphology and can be remodeled with apparatus  8 . Any surface irregularity with depressions and elevations will have vectors directed to the lowest point of the deformity. Prominent “pores” or acne scaring of the skin have a similar pattern to cellulite but on a smaller scale and can also be treated with apparatus  8 . Clinically, the application of the mechanical force reduces the power required to remodel the matrix and diminishes cell necrosis of the skin surface as well as underlying soft tissue structures. Compression alters the extracellular fluid of the soft tissue structure (collagen) and exerts electrical impedance and thermal conductivity effects that allow delineation of a conduit-treatment interface of the collagen containing tissues. A deeper dermal interface will contract skin and exert three dimensional contour effects while a more superficial interface will smooth surface morphology.  
     [0118] In circumstances in which expansion of the skin envelope is needed, the combined application of heat and pressure can also be utilized with various embodiments of patient feedback to control one or both parameters. For breast reconstruction, expansion of the skin envelope can be achieved with each inflation of a subpectoral breast expander. FIGS.  10 ( a ) and  10 ( b ) illustrate an expander with an RF receiver electrode. A telescoping segment with an RF energy source is incorporated with access valve and is used to expand a nipple areolar donor site for Pectoralis “Peg” Procedure. The segmental expander can also be used to prepare the recipient site for delayed autologous “Peg” Flap. The pressure that is exerted on the skin and the periprosthetic scar capsule is from the inside. In this application, vectors are directed outward. As an adjunct to this expansion process, a controlled thermal pad may be incorporated into a bra, as illustrated in FIG. 10( c ), which can be applied to the inferior pole of the breast skin to promote lengthening of collagen fibril within the skin and underlying scar capsule around the expander. The bra may also function as an external conforming template  12  to achieve a specific breast shape. The net result is the creation of a more esthetic breast reconstruction with three-dimensional characteristics of the opposite breast. In a like manner, other garments can be utilized as external conforming templates for other anatomical body structures. In FIG. 10( d ) a breast expander is partially expanded within the breast. In FIG. 10( e ), the expander is fully expanded within the breast.  
     [0119] Template  12  can be configured to apply a mechanical force in combination with the delivery of energy to the skin surface and underlying soft tissue structure, to remodel collagen both esthetically and functionally with minimal thermal damage including cell necrosis. Additionally, template  12  can be configured (as described herein) to deliver both mechanical force and energy while minimizing or reducing edge effects. These effects comprise both electrical and pressure edge effects describe herein.  
     [0120] In various embodiments, template  12  can be configured to treat a variety of human anatomical structures (both internal and external) and accordingly, can have a variety of different forms and shapes. One embodiment of such a form is a garment that is illustrated in FIG. 11. An energy source  22  can be directly incorporated into the fabric of a tight fitting garment or inserted as a heating or RF electrode pad into a pocket of the garment. Another example of a garment is a tight fitting bra that extends over the arm and waistline with zone control that provides contraction of the skin of the breast, arms, and waistline to a variable amount to create a desired three-dimensional figure. Functional remodeling of collagen containing structures includes a variety of different applications for aesthetic remodeling.  
     [0121] As shown in FIGS.  12 ( a ) and  12 ( b ), in various embodiments template  12  can be a garment positioned over the nose, around the ear, or other facial structure. Template  12  can also be applied for functional purposes. Referring now to FIGS. 13 and 14, pre-term cervical dilation can be treated with a template  12  that is configured to have the impression or form of a “competent” cervix. The cervical template  12  creates vectors that contract the circumference of the cervix. The incorporated energy delivery device  18  contracts the native matrix and induces scar collagen. The dilated cervical OS is tightened and the entire cervix is strengthened. Energy delivery device  18  can be incorporated into template  12  which can be the cervical conformer and inserted as a vaginal obturator. It will be appreciated that template  12  can be utilized for other functional treatments.  
     [0122] In another embodiment, template  12  is a functional appliance that may be non-conforming and can be separate or incorporated with the energy delivery device  18 . Orthodontic braces that are designed in conjunction with energy delivery device  18  are used to remodel dental collagen and apply rotation and inclination vectors on the neck of the tooth which is devoid of enamel. In FIG. 15( a ) orthodontic braces are coupled to RF electrodes and associated power source. The orthodontic braces function as a non-conforming force application surface that is coupled to incorporated RF electrodes. FIGS.  15 ( b ) and  15 ( c ) illustrates a orthodontic appliance that is a conforming template  12  coupled to RF electrodes. As a consequence, orthodontic correction is more rapidly achieved than current modalities that employ only mechanical forces. Orthodontic correction can also be achieved with a conforming template  12  that is the corrected impression of the patient&#39;s dentition.  
     [0123] For orthopedic applications, an external fixation device is used as a non-conforming functional appliance. This appliance is used in tandem with an energy source device, including but not limited to RF electrodes, that remodels the collagen of the callus tissue. More accurate alignment of osteotomy and fracture sites are possible with either a conforming or nonconforming brace that is used in tandem or is directly incorporated into energy delivery device  18 . Improved range of motion of contracted joints and correction of postural (spinal) deformities can be achieved with this combined approach.  
     [0124] The ability to remodel soft tissue in anatomical structures other than skin can be dependent upon the presence of preexisting native collagen. In tissue devoid or deficient of native collagen, energy and/or force and can be delivered to cause an induction or formation of scar collagen. Template  12  can be used to remodel the subcutaneous fat of hips and thighs in addition to the tightening of the skin envelope. The convolutions of the ear cartilage can be altered to correct a congenital prominence. The nasal tip can be conformed to a more esthetically pleasing contour without surgery.  
     [0125] Template  12  can be used with any modality that remodels collagen including but not limited to the applications of heat, electromagnetic energy, force and chemical treatment, singularly or in combination. In addition to RF (e.g. molecular) remodeling of collagen, cellular modalities that invoke the wound healing sequence can be combined with a conforming esthetic template. Thermal and chemical treatments (e.g. glycolic acid) induce a low-level inflammatory reaction of the skin. Scar collagen induction and fibroblastic (cellular) contraction are directed into converging and diverging vectors by a conformer that produces a smoother and tighter skin envelope. In addition to achieving a smoother and tighter integument, the texture of the skin is also improved with this remodeling process. Older or less compliant skin has a greater number of intermolecular crosslinks in the dermal collagen than younger skin. Scar collagen induction with cleavage of crosslinks will produce a softer and more compliant skin envelope.  
     [0126] Cutaneous applications for apparatus  8  and/or embodiments of patient feedback methods can include one or more of the following: (i) Non invasive skin rejuvenation with the replacement of elastoic sun damaged collagen in the dermis with nascent scar collagen, (ii) on invasive hair removal, without epidermal burning, (iii) Hair growth with intracellular induction of the hair follicle, (iv) Non invasive reduction of sweating and body odor, (v) Non invasive reduction of sebaceous gland production of oil as a treatment of an excessively oily complexion, and (vi) Non invasive treatment of dilated dermal capillaries (spider veins). Non-cutaneous applications for apparatus  8  can include the following: (i) Non invasive treatment of preterm delivery due to an incompetent cervix, (ii) Non invasive treatment of pelvic prolapse and stress incontinence, (iii) Non invasive treatment of anal incontinence, (iv) Non invasive creation of a continent ileostomy or colostomy, and (v) Non invasive (or minimally invasive through an endoscope) correction of a hernia or diastasis.  
     [0127] Referring now to FIGS. 16 and 17, template  12  can be stationary or mobile. A hand held conforming template  12  that is mobile provides the practitioner with greater flexibility to remodel the collagen matrix and surrounding tissue. Pressure (e.g. force) and impedance changes can serve as a guide for the manual application of template  12 . A hand held template  12  with an incorporated energy source  22  and energy delivery devices  18  may be applied over a conductive garment that provides three dimensional conformance to the treatment area. Less accessible areas can be remodeled with this particular device. In one embodiment shown in FIG. 16, template  12  is made of a semi-solid material that conforms a lax skin envelope to an underlying soft tissue structure. The semi-solid material allows for the customized shaping of force application surface  14  and reduces the need for precise fabrication of an esthetic template. Suitable semi-solid materials include compliant plastics that are thermally and electrically conductive. Such plastics include but are not limited to silicone, polyurethane and polytetrafluoroethylene coated or otherwise embedded with an electrically or thermally conductive metal such as copper, silver, silver chloride, gold, platinum or other conductive metal known in the art.  
     [0128] Controlled remodeling of collagen containing tissue can be accomplished using an electromagnetic device that lengthens or contracts the matrix with a minimum of cell necrosis. Energy delivery devices suited to this purpose include one or more RF electrodes. Accordingly, energy delivery device  18  can include a plurality of RF electrodes with or without insulation. The non-insulated sections of the RF electrodes collectively form template energy delivery surface  20 . In a similar manner, in various other embodiments microwave antennas, optical waveguides, ultrasound transducers and energy delivery or energy remove fluids can be used to form template energy delivery surface  20 . Individual electrodes  18  and the like can be multiplexed and to provide selectable delivery of energy.  
     [0129] Referring now to FIGS. 18 a  and  18   b , when energy delivery device  18  is an RF electrode, energy source  22  is a RF generator well known in the art, together they can comprise an RF energy delivery system  26 . RF energy system  26  can be operated in either a bipolar or a monopolar configuration as is well known in the art of electro-surgery. Also RF energy delivery system  26  can be configured to be used in one or more embodiments of tissue treatment with patient feedback described herein. For example, the delivery system can include power setting that can be calibrated to particular levels of patient thermal/pain sensation.  
     [0130] A monopolar RF energy system  26 ′ tends to behave as a series circuit if tissue surface impedance is uniform. In various monopolar embodiments, tissue surface impedance can both be reduced and made more uniform by hydration of the skin surface and/or underlying tissue. This in turn can reduce resistive heating of the skin surface. Such a monopolar system configuration will be less likely to produce high current density shorts than a bipolar system. The resulting electrical field will also have greater depth if heating of subjacent tissues is desired. It is predicted that the application of uniform compressive forces to the skin with monopolar RF systems can be used to actively remodel the dermis instead of being a factor that causes a combined edge effect at the skin surface. In addition, a monopolar system  26 ′ can be configured to provide a choice of two treatment surfaces. Another embodiment of a monopolar system  26 ′ involves the combination of RF lipolysis at the active electrode with skin contraction at the passive electrode tissue interface  19 ′ and surrounding tissue′.  
     [0131] As shown in FIG. 18 a , in a monopolar RF energy system  26 ′, current flows from RF energy source  22  to the RF electrode  18  also known as the active electrode  18 , into the patient and then returns back to RF generator  22  via a second electrode  19  known as a passive electrode  19 , return electrode  19 , or ground pad  19  which is in electrical contact with the skin of the patient (e.g. the thigh or back). In various embodiments, RF electrode  18  can be constructed from a variety of materials including but not limited to stainless steel, silver, gold, platinum or other conductor known in the art. Combinations or alloys of the aforementioned materials may also be used.  
     [0132] Ground pad  19  can be configured to serve to both provide a return path for electrical current  27  from electrode  18  to electrical ground and disperse the current density at ground pad tissue interface  19 ′ to a sufficiently low level so as to prevent a significant temperature rise and or thermal injury at interface  19 ′. Ground pad  19  can be either a pad or a plate as is well known in the art. Plates are usually rigid and made of metal or foil-covered cardboard requiring use of a conductive gel; pads are usually flexible. Suitable geometries for ground pad  19  include circular, oval or rectangular (with curved corners) shapes. Heating at tissue interface  19  can be reduced in various embodiments in which ground pad  19  has a radial taper  19 ″. Ground pad  19  may also contain a heat transfer fluid or be coated with a thermally conductive material to facilitate even distributions of heat over the pad, reduce hot spots and reduce the likelihood of thermal injury at tissue interface  19 ′. Also ground pad  19  and the interface  19 ′ between groundpad  19  and the patient is of sufficiently low impedance to prevent the phenomena of current division, or electrical current flowing to ground by an alternate path of least resistance and potentially burning of the patients skin at an alternate grounded site on the patient. Furthermore, ground pad  19  is of sufficient surface area with respect to both the patient and with RF electrode  18  such that the return current is dispersed to a level that the current density at interface  19 ′ is significantly below a level that would cause damage or any appreciable heating of tissue at interface  19 ′ or any other part of the body except in the area  21  in immediate proximity to RF electrode  18 . In various embodiments, the surface area of ground pad  19  can range from 0.25 to 5 square feet, with specific embodiments of 1, 2, 3 and 4 square feet.  
     [0133] In alternative embodiments, grounding pad  19  is used as the surface treatment electrode. That is, it functions to produce a heating effect at tissue interface  19 ′ in contact with ground pad  19 . In these embodiments, the surface area of ground pad  19  is small enough relative to both the patient and/or RF electrode  18  such that ground pad  19  acts as the active electrode. Also, RF electrode  18  has a large enough surface area/volume (relative to the patient) not to produce a heating effect at energy delivery surface  20 . Also, ground pad  19  is positioned at the desired treatment site, while RF electrode  18  is electrically coupled to the patients skin  9 ′ a sufficient distance away from return electrode  19  to allow sufficient dispersion of RF current  27  flowing through the patient to decrease the current density and prevent any heating effect beside that occurring at pad interface  19 ′. In this embodiment, fluid delivery device  13  can be incorporated into the ground pad  19 . The subjacent skin can be hydrated to reduce resistive heating and provide a more uniform impedance that can avoid parallel shorts through localized areas of low impedance. At a distant tissue site, active electrode  18  is applied either topically cooled or inserted percutaneously with a sheathed electrode that avoids burning of the skin. The active electrode  18  will be typically positioned in the subcutaneous fat layer. The fat is injected with a saline solution to lower current density which will in turn diminish burning of the subcutaneous tissue. If significant burning of the subcutaneous tissue occurs, this site can be positioned on the lower abdomen for an aesthetic excision.  
     [0134] Referring now to FIG. 18 b , in a bipolar RF energy system  26 ″, individual RF electrodes  18  have positive and negative poles  29  and  29 ′. Current flows from the positive pole  29  of one electrode to its negative pole  29 ′, or in a multiple electrode embodiment, from the positive pole  29  of one electrode to the negative pole  29 ′ of an adjacent electrode. Also in a bipolar embodiment, the surface of a soft or conformable electrode  18  is covered by a semiconductive material describe herein. Also in a bipolar system it is important that the force applied by force applications surface  14  to tissue interface  21  be limited to that amount necessary only to achieve and maintain contact with the skin. This can be achieved through the use of a feedback control system described herein.  
     [0135] In various embodiments, RF electrode  18  can be configured to minimize electromagnetic edge effects that cause high concentrations of current density on the edges of the electrode. By increasing current density, edge effects cause hot spots in tissue interface  21  or on the edges of the electrode resulting in thermal damage to the skin and underlying tissue at or near tissue interface  21 . In an embodiment, edge effects can be minimized by moving the electrode  18  in response to patient feedback to reduce overheating at the electrode edges.  
     [0136] Referring now to FIGS. 19 a  and  19   b , the reduction of edge effects can be accomplished by optimizing one or more of the geometry, design and construction of RF electrode  18 . Electrode geometries suited for reducing edge effects and hot spots in RF electrode  18  and tissue interface  21  include substantially circular and oval discs with a radiused edge  18 ″. For the cylindrical configuration edge effects are minimized by maximizing the aspect ratios of the electrode (e.g. diameter/thickness). In a specific embodiment, edge effects can be also reduced through the use of a radial taper  43  in a circular or oval shaped electrode  18 . In related embodiments, the edges  18 ″ of electrode  18  are sufficiently curved (e.g. have a sufficient radius of curvature) or otherwise lacking in sharp comers so as to minimize electrical edge effects.  
     [0137] Referring now to FIGS. 20 a  and  20   b , there are several other embodiments of RF electrode  18  that can reduce edge effects. One embodiment illustrated in FIG. 20 a , involves the use of a soft or conforming electrode  18  that has a soft or conforming layer  37  over all or a portion of its energy delivery surface  20 . Conforming layer  37  can be fabricated from compliant polymers that are embedded or coated with one or more conducting materials (in the case of monopolar embodiments described herein) including, but not limited to silver, silver chloride, gold or platinum.  
     [0138] In bipolar embodiments, conforming layer  37  is coated or otherwise fabricated from semiconductive materials described herein. The polymers used are engineered to be sufficiently compliant and flexible to conform to the surface of the skin while not protruding into the skin, particularly along an edge of the electrode. The conductive coatings can be applied using electro-deposition or dip coating techniques well known in the art. Suitable polymers include elastomers such as silicone and polyurethanes (in membrane or foam form) and polytetrafluoroethylene. In one embodiment the conformable template surface  37  will overlap the perimeter  18 ″ of electrode  18  and cover any internal supporting structure. In another embodiment the entire surface  20  of electrode  18  is covered by conforming layer  37 .  
     [0139] Referring now to FIG. 20 b , in various embodiments, particularly those using an array of RF electrodes  18 , edge effects at the electrode tissue interface  21  can be reduced by the use of a semiconductive material template  31  or substrate  31  located between or otherwise surrounding electrodes  18 . In various embodiments, the conductivity (or impedance) of semiconductive substrate  31  can range from 10 −4  to 10 −3  (ohm-cm). −1 , with specific embodiments of 10 −4  and 1 (ohm-cm) −1 . The conductivity (or impedance) of substrate  31  can also vary in a radial  31  ′ or longitudinal direction  31 ″ resulting in an impedance gradient.  
     [0140] In various embodiments, surrounding means that substrate  31  is in contact with and/or provides an electrical impedance at all or a portion of electrode  18 , including but not limited to, only one or more surfaces  18 ′, and one or more edges  18 ″. In this and related embodiments substrate  31  is an insulating material with a conductivity of 10 −6  (ohm-cm) −1  or lower.  
     [0141] The impedance of the semiconductive template  31  can be variable in relation to electrode position within template. The template impedance has a specific pattern that reduces hot spots on the tissue surface  9 ′ by reducing current density at locations more likely to have higher current densities such as edges of individual electrodes and the array itself In one embodiment, the impedance of template  31  is larger at the electrode perimeter or edges  18 ″. Also in various embodiments, electrode shape and topographical geometry are incorporated into the variable impedance topography of semiconductive template  31  between the electrodes. As a result, a more uniform current density is achieved that prevents or reduces thermal damage of tissue at or nearby tissue interface  21 . The specific electrode shape, geometry and distribution pattern on the variable impedance template  31  as well as the pattern of impedance variation over the template surface  31 ′ can be modeled and designed using a software simulation (such as a finite element analysis program) that is adapted for the overall three-dimensional contour of a specific device.  
     [0142] In addition to electromagnetic edge effects described herein, pressure edge affects may also result with the use of a rigid materials in force application surface  14  that tend to concentrate force on the edges of force application surface  14  and/or electrode  18 . Such force concentrations can damage skin and underlying tissue and also cause hot spots due to increased RF energy delivery and/or increased heat transfer at the areas of force concentration.  
     [0143] Referring now to FIG. 21, to eliminate these force concentrations and their effects, the shape and material selection, of template  12  can be configured to provide a cushioned or conformable template surface or layer  12 ′ that is incorporated into the framework of template  12  and force application surface  14  (i.e., the conformable template surface will overlap the perimeter and encompass any internal supporting member). In a specific embodiment, the entire surface of template  12  and/or force application surface  14  is covered by a conformable layer  12 ′ (similar to conformable layer  37 ) that is made of a semiconductive (for bipolar applications) or conductive (for monopolar applications) material that avoid enhanced pressure or electrical edge effects described herein. In another embodiment template  12  can have a laminated or layered construction whereby conformable layer  12 ′ is joined or otherwise coupled to an inner rigid layer  12 ″ (via adhesive bonding, ultrasonic welding or other joining method known in the art). Rigid layer  12  facilitated the in the transmission/application of force  17  to tissue but does not contact tissue itself.  
     [0144] In various embodiments, conformable layer  12 ′ can be constructed of conformable materials with similar properties as conformable layer  37 . Materials with suitable conformable properties include various conformable polymers known in the art including, but not limited to polyurethanes, silicones and polytetrafluoroethylene. The polymer materials can be coated with conductive materials such as silver, silver chloride, and gold; or semiconductive coatings such as vapor-deposited germanium (described in U.S. Pat. No. 5,373,305 which is incorporated by reference herein) using electro/vapor deposition or dip coating techniques, or constructed with semiconductive polymers such as metallophthalocyanines using polymer processing techniques known in the art. In various embodiments, the thickness and durometer of polymers used for force application surface  14  and/or RF electrode  18  can be further configured to: i) produce a uniform distribution of applied force across the electrode tissue interface  21  or ii) produce a gradient in stiffness and resulting applied force  17  across energy delivery surface  20 . In an embodiment, force applications surface  14  and/or energy delivery surface  20  are configured to have maximum applied force  17  at their respective centers and decreasing applied force moving outward in the radial direction. In other embodiments, force application surface  14  can be engineered to produce varying force profiles or gradients at tissue interface  21  with respect to radial direction of template  12 , force applications surface  14 , or energy delivery surface  20 . Possible force profiles include linear, stepped, curved, logarithmic with a minimum force at tissue interface edge  21 ′ or force application edge  14 ′ and increasing force moving in an inward radial direction. In a related embodiment, gradients in bending and compressive stiffness can be produced solely by varying the thickness of force application surface  14 , electrode  18  or energy delivery surface  20  in their respective radial directions. In an embodiment, force application surface  14  and/or electrode  18  have a maximum thickness and bending stiffness at their respective centers with a tapered decreasing thickness (and corresponding stiffness) moving out in their respective radial directions.  
     [0145] In various embodiments, monitoring of both active electrode  18  and passive electrode  19  may be employed to prevent or minimize unwanted currents due to insulation breakdown, excessive capacitive coupling or current division. An active electrode monitoring system  38  shown in FIG. 22, uses a monitoring unit  38 ′ to continuously monitor the level of stray current  27 ′ flowing out of electrode  18  and interrupts the power should a dangerous level of leakage occur. Stray currents  27 ′ include currents due to capacitive coupling and/or insulation failure of electrode  18 . In various embodiments monitoring unit  38 ′ can be integrated into or otherwise electronically coupled with a control system  54  and current monitoring circuitry described herein. Monitoring system  38  may also be configured to conduct stray current from the active electrode back to the RF generator and away from patient tissue. Monitoring system  38  can also be configured to be used with one or more forms of patient feedback described herein including biometric feedback.  
     [0146] Monitoring unit  38 ′ can comprise electronic control and measurement circuitry for monitoring impedance, voltage, current and temperature well known in the art. Unit  38 ′ may also include a digital computer/microprocessors such as an application specific integrated circuit (ASIC) or a commercial microprocessor (such as the Intel® Pentium® series) with embedded monitoring and control software and input/output ports for electrical connections to sensors  23  and other measurement circuitry, to active electrode  18 , passive electrode  19 , RF generator  22  and other electrical connections including connections to the patient and ground. Monitoring unit  38 ′ may also be incorporated into RF generator  22 .  
     [0147] In another embodiment monitoring system  38  is configured as a passive electrode monitoring system  39 ′ that is used to monitor the passive electrode  19  and shut down current flow from RF generator  22  should the impedance of passive electrode  19  or interface  19 ′ becomes too high or temperature at the interface  19 ′ rise above a set threshold. In these embodiments, passive electrode  19  is a split conductive surface electrode (known in the art) which can measure impedance at the interface  19 ′ between patient tissue and the patient return electrode itself and avoid tissue bums. Prevention of pad bums is also facilitated by the coupling of temperature monitoring, impedance and/or contact sensors  23  (such as thermocouples or thermistors) to pad  19  and a monitoring unit  39 ′ (which can be the same as monitoring unit  38 ′ and likewise coupled to control system  54 ). Contact or impedance sensors  23  allows unit  39 ′ to monitor the amount of electrical contact area  19 ′″ of pad  19  that is in electrical contact with the skin and shut down or otherwise alarm should the amount of contact area fall below a minimum amount. Suitable contact sensors include pressure sensors, capacitance sensors, or resistors in suitable ranges and values known in the art for detecting electrical contact with the skin.  
     [0148] Referring now to FIGS. 1, 22 and  23 , in various embodiments, elements of apparatus  8  can be coupled to an open or closed loop feedback control system  54  (also called control system  54 , control resources  54  and resources  54 ). Control system  54  can be configured used to control the delivery of electromagnetic and mechanical energy to the skin surface and underlying soft tissue structure to minimize, and even eliminate, thermal damage to the skin and underlying tissue cell necrosis as well as blistering of the skin surface. Control system  54  can be configured to be used with one or more embodiments of patient feedback described herein, including verbal and biometric feedback. Also control system  54  can be configured to be used with one or more embodiments of patient feedback methods described herein including verbal and biometric feedback and combinations thereof.  
     [0149] Control system  54  can be configured to monitor other parameters including but not limited to, the presence of an open circuit, short circuit or if voltage and current are supplied to the tissue for more than a predetermined maximum amount of time. Such conditions may indicate a problem with various components of apparatus  8  including RF generator  22 , and monitoring unit  38 ′ or  39 ′. Control system  54  can also be configured to control the delivery of energy to selected tissue including epidermal, dermal, and subdermal over a range of skin thermal conductivities including, but not limited to, the range of about 0.2 to about 1.2 W/(m 2  C). In various embodiments, control system  54  can include a digital computer or microprocessors such as an application specific integrated circuit (ASIC) or a commercial microprocessor (such as the Intel.® Pentium® series) with embedded monitoring and control software and input/output ports for electrical connections to sensors  23  and other measurement circuitry. In a related embodiment, control system  54  can comprise an energy control signal generator that generates an energy control signal.  
     [0150] In an alternative embodiment control system  54  can be integral to a separate device or instrument  54 ′ that is coupled to one or more of fluid delivery devices  13 , energy delivery devices  18 , power source  22 , sensors  23  or a patient feedback input device  54 ″. Device  54 ′ can comprise a microcomputer, processor or PDA device known in the art. Patient feedback input device  54 ″ can be configured to allow the patient or physician to input patient feedback in a variety of forms including, but not limited to, a patient pain/thermal sensitivity scale describe herein which can be manually or verbally entered. Other feedback can include one or more biometric parameters described herein. In an embodiment patient feedback input device  54 ″ can comprise a handheld computer, PDA device, keyboard, touch screen, mouse, control knob, electronic sip-straw, joystick, microphone, speech recognition device, CCD, electronic camera or other input/output device known in the art.  
     [0151] Referring now to FIG. 23, an open or closed loop feedback control system  54  couples sensor  346  to energy source  392  (also called power source  392 ). In this embodiment, electrode  314  is one or more RF electrodes  314 , however other energy delivery devices described herein are equally suitable. The temperature of the tissue, or of RF electrode  314 , is monitored, and the output power of energy source  392  adjusted accordingly. The physician can, if desired, override the closed or open loop control system  54 . A microprocessor  394  can be included and incorporated in the closed or open loop system to switch power on and off, as well as modulate the power. Closed loop feedback control system  54  utilizes microprocessor  394  to serve as a controller, monitor the temperature, adjust the RF power, analyze the result, refeed the result, and then modulate the power.  
     [0152] With the use of sensor  346  and feedback control system  54 , tissue adjacent to RF electrode  314  can be maintained at a desired temperature for a selected period of time without causing a shut down of the power circuit to electrode  314  due to the development of excessive electrical impedance at electrode  314  or adjacent tissue as is discussed herein. Each RF electrode  314  is connected to resource that generate an independent output. The output maintains a selected energy at RF electrode  314  for a selected length of time.  
     [0153] Current delivered through RF electrode  314  is measured by current sensor  396 . Voltage is measured by voltage sensor  398 . Impedance and power are then calculated at power and impedance calculation device  400 . These values can then be displayed at user interface and display  402 . Signals representative of power and impedance values are received by a controller  404 . A control signal  404 ′ (also called energy control signal  404 ′) is generated by controller  404  that is proportional to the difference between an actual measured value, and a desired value. The control signal is used by power circuits  406  to adjust the power output an appropriate amount in order to maintain the desired power delivered at respective RF electrodes  314 .  
     [0154] In a similar manner, temperatures detected at sensor  346  provide feedback for maintaining a selected power. Temperature at sensor  346  is used as a safety means to interrupt the delivery of power when maximum pre-set temperatures are exceeded. The actual temperatures are measured at temperature measurement device  408 , and the temperatures are displayed at user interface and display  402 . A control signal is generated by controller  404  that is proportional to the difference between an actual measured temperature and a desired temperature. The control signal is used by power circuits  406  to adjust the power output an appropriate amount in order to maintain the desired temperature delivered at the sensor  346 . A multiplexer can be included to measure current, voltage and temperature, at the sensor  346 , and energy can be delivered to RF electrode  314  in monopolar or bipolar fashion.  
     [0155] Controller  404  can be a digital or analog controller, or a computer with software. When controller  404  is a computer it can include a CPU coupled through a system bus. This system can include a keyboard, a disk drive or other non-volatile memory device or computer readable storage medium, a display, and other peripherals, as are known in the art. A program memory and a data memory are also coupled to the bus. User interface and display  402  includes operator controls and a display. Controller  404  can be coupled to imaging systems including, but not limited to, ultrasound, CT scanners, X-ray, MRI, mammographic X-ray and the like. Further, direct visualization and tactile imaging can be utilized.  
     [0156] The output of current sensor  396  and voltage sensor  398  are used by controller  404  to maintain a selected power level at each RF electrode  314  and also to monitor stray currents  427 ′ (dues to insulation failure or capacitive coupling) flowing from electrode  314 . The amount of RF energy delivered controls the amount of power. A profile of the power delivered to electrode  314  can be incorporated in controller  404  and a preset amount of energy to be delivered may also be profiled. Also, should stray current  427 ′ rise to an undesired level, controller  404  shuts down power source  392 .  
     [0157] Circuitry, software and feedback to controller  404  result in process control, the maintenance of the selected power setting which is independent of changes in voltage or current, and is used to change the following process variables: (i) the selected power setting, (ii) the duty cycle (e.g., on-off time), (iii) bipolar or monopolar energy delivery; and, (iv) fluid delivery, including flow rate and pressure. These process variables are controlled and varied, while maintaining the desired delivery of power independent of changes in voltage or current, based on temperatures monitored at sensor  346 .  
     [0158] Referring now to FIG. 24, current sensor  396  and voltage sensor  398  are connected to the input of an analog amplifier  410 . Analog amplifier  410  can be a conventional differential amplifier circuit for use with sensor  346 . The output of analog amplifier  410  is sequentially connected by an analog multiplexer  412  to the input of A/D converter  414 . The output of analog amplifier  410  is a voltage, which represents the respective sensed temperatures. Digitized amplifier output voltages are supplied by A/D converter  414  to microprocessor  394 . Microprocessor  394  may be a MPC601(PowerPC®) available from Motorola or a Pentium® series microprocessor available from Intel®. In specific embodiments microprocessor  394  has a clock speed of 100 Mhz or faster and includes an on-board math-coprocessor. However, it will be appreciated that any suitable microprocessor or general purpose digital or analog computer can be used to calculate impedance or temperature.  
     [0159] Microprocessor  394  sequentially receives and stores digital representations of impedance and temperature. Each digital value received by microprocessor  394  corresponds to different temperatures and impedances. Calculated power and impedance values can be indicated on user interface and display  402 . Alternatively, or in addition to the numerical indication of power or inpedance, calculated impedance and power values can be compared by microprocessor  394  to power and impedance limits. When the values exceed or fall below predetermined power or impedance values, a warning can be given on user interface and display  402 , and additionally, the delivery of RF energy can be reduced, modified or interrupted. A control signal from microprocessor  394  can modify the power level supplied by energy source  392 .  
     [0160]FIG. 25 illustrates a block diagram of a temperature and impedance feedback system that can be used to control the delivery of energy to tissue site  416  by energy source  392  and the delivery of cooling medium  450  to electrode  314  and/or tissue site  416  by flow regulator  418 . Energy is delivered to RF electrode  314  by energy source  392 , and applied to tissue site  416 . A monitor  420  (also called impedance monitoring device  420 ) ascertains tissue impedance (at electrode  314 , tissue site  416  or a passive electrode  314 ′), based on the energy delivered to tissue, and compares the measured impedance value to a set value. If measured impedance is within acceptable limits, energy continues to be applied to the tissue. However if the measured impedance exceeds the set value, a disabling signal  422  is transmitted to energy source  392 , ceasing further delivery of energy to RF electrode  314 . The use of impedance monitoring with control system  54  provides a controlled delivery of energy to tissue site  416  (also called mucosal layer  416 ) and underlying cervical soft tissue structure which reduces, and even eliminates, cell necrosis and other thermal damage to mucosal layer  416 . Impedance monitoring device  420  is also used to monitor other conditions and parameters including, but not limited to, presence of an open circuit, short circuit; or if the current/energy delivery to the tissue has exceeded a predetermined time threshold. Such conditions may indicate a problem with apparatus  24 . Open circuits are detected when impedance falls below a set value, while short circuits and exceeded power delivery times are detected when impedance exceeds a set value  
     [0161] In an embodiment, the control of cooling medium  450  to electrode  314  and/or tissue site  416  is done in the following manner. During the application of energy, temperature measurement device  408  measures the temperature of tissue site  416  and/or RF electrode  314 . A comparator  424  receives a signal representative of the measured temperature and compares this value to a pre-set signal representative of the desired temperature. If the measured temperature has not exceeded the desired temperature, comparator  424  sends a signal  424 ′ to flow regulator  418  to maintain the cooling solution flow rate at its existing level. However if the tissue temperature is too high, comparator  424  sends a signal  424 ″ to a flow regulator  418  (connected to an electronically controlled micropump, not shown) representing a need for an increased cooling medium  450  flow rate.  
     [0162] In various embodiments, feedback can be incorporated into a tissue treatment procedure or skin tightening procedure in a variety of different manners. These varied approaches can be adapted for use with exemplary apparatus  8  or other energy delivery apparatus known in the art. Referring to FIG. 26 in various embodiments, patient feedback can be used to control the delivery of energy or cooling, or both to a target tissue site  9  by communicating signaling or otherwise coupling patient feedback or feedback signals  54   s  to one or more of the energy delivery device  18 , energy source  22 , cooling device  13 , a feedback control system  54  or a manual control device  54 ″ actuated by the physician or the patient or both. The feedback control system  54  can be coupled to one or both of the energy source  22 , fluid delivery or cooling device  13 .  
     [0163] Referring now to FIG. 27, in related embodiments correlations can be established between measured physiological or biometric signals  54   bs  indicative of thermal/pain sensations (e.g. vasodilation, skin conductivity, temperature etc) and a patient determined scale  54   ps  of thermal/pain sensation such as the three level scale described herein. The use of such a correlation allows control system  54  to provide a faster or more sensitive indicator of pain or thermal injury than could be communicated by the patient. The correlation can be done before the procedure and can be repeated over the course of a procedure as needed to account for variations in tissue properties and changes in patient perceptions. In alternative embodiments, the correlation can be continuously updated over the course of the treatment as the patient provides ongoing verbal indications of their level of pain/thermal sensation. Also the correlation procedure can be repeated for different tissue sites as needed. In various embodiments, the correlation(s) can be computed and stored in control system device  54 ′, feedback entry device  54 ″ and/or a database  60   db  using biomedical data acquisition, signal analysis or feedback algorithms known in the art. Device  54 ′ or  54 ″ can be configured to allow the physician to select between use of biometric or patient verbal feedback or a combination of both. In use, this approach can allow for a more sensitive and accurate indication of patient pain/thermal sensation during a procedure and in turn provide more precise or fine tuned control of energy delivery to achieve a selectable tissue affect.  
     [0164] In various embodiments, biometric feedback can include a plurality of signals  54   s . In an embodiment shown in FIG. 28, this plurality can include a first  54 s 1  and a second signal  54 s 2 , wherein the combination of the first and the second signal is used to determine or provide an indication of a patient perceived sensation of tissue heating or pain. In an embodiment the signals can be the same parameter  54   p  but from different locations on the body, for example, the target tissue site  9  and a non-target tissue site  9   n , which can be a contralateral site (e.g. the opposite cheek face) to target site  9 . In use, these and related embodiments can provide increased sensitivities to changes in tissue properties indicative of thermal affect or injury by utilizing real-time comparisons between a control and target tissue site. Also sites indicative of various physiological responses of pain or heat (such as vasodialation, vasoconstriction, sweating, etc) can also be chosen. Examples of such sites include without limitation, the hand, fingers, fingertips, forehead, mouth, lips and the like.  
     [0165] In an alternative embodiment, the feedback signals can be different biometric parameters  54   p ′, for example temperature and skin conductivity/impedance, or temperature and skin absorbance/reflectance. In use multiple biometric parameters can provide for increased sensitivity to one or more physiologic responses indicative of pain, heat or thermal damage.  
     [0166] Referring back to FIG. 26, in an embodiment the feedback control system can include a software feedback control module  54   m  electronically stored in device  54 ′ or  54 ″ or other logic resources  54   lr  known in the art. The feedback module  54   m  can include stored software programs or electronic instructions sets  54   m ′ as well as database  60   db  configured for performing one or more of the following functions: (i) controlling or facilitating the pain or thermal sensation calibration procedures described herein; (ii) controlling the delivery of energy (including power levels, power profiles (e.g. ramps and curves), duty cycles); (iii) controlling the delivery of cooling media; (iv) receiving biometric data from the patient and controlling energy delivery or cooling media delivery responsive to that input; (v) receiving patient verbal feedback (using speech recognition software known in the art and controlling the delivery of energy or cooling responsive to that verbal feedback; (vi) providing the physician with auditory or visual prompts in performing the procedure; (vii) convert or modify the pain or thermal sensation calibration scale for different tissue sites and procedures; (viii) monitor various patient data and provide the physician alarms for various patient conditions (e.g. heart rate, degree of tissue damage, etc.); (ix) capture images of the tissue site such as video, ultrasound, thermo-graphic and infrared images before during or after the procedure; (x) display images of the tissue site before, during and/or after a treatment; and (xi) display a template overlay, visual cues or pointers superimposed on an a tissue site image to assist the physician with the procedure.  
     [0167] The manual control device  54 ″ can be configured to allow either the medical practioner or patient to control the delivery of energy, heat or cooling to the tissue site. Such control of energy can include attenuation, complete cessation, cessation for a fixed period or increased delivery for selectable periods. Other embodiments can be configured to allow for simultaneous or near simultaneous control of both the delivery of energy and cooling. For example, energy delivery can be decreased while cooling delivery is increased.  
     [0168] In use, patient feedback can allow the physician to use a single and simple indicator to regulate or titrate the delivery of energy to a selected tissue site to achieve a selectable tissue affect such as skin tightening, remodeling or rejuvenation. Specifically, by quantifying patient sensation, the delivery of net energy to the target tissue can be linked to the variation of a single modality where the energy output of the device is titrated to the patient&#39;s perception of heat or pain. Even though pain tolerances can vary from patient to patient, the perceived heat or pain by the patient can have a consistent relationship to the net energy delivered by the source of energy. In alternative embodiments, erythema (or another skin optical or thermal property indicative to tissue injury) can be used as an indicator for titrating energy delivery and/or cooling. For example, a particular site can be retreated if it does not exhibit erythema, or energy delivery reduced or ceased once erythema begins to appear. The level of erythema can be determined visually, or via an imaging device, thermo-graphic imaging device such as in infrared camera or a spectrophotometric measurement device known in the art. In various embodiments, use of one or more of these imaging devices can be coupled to logic resources that includes a module (e.g., module  54   m ) or algorithm for determination of eryrthema based on comparison of real-time measurements to baseline measurement for a given patient or a eryrthema measurement database for skin types, skin location or combination of both or other physiological parameters (e.g. age, sex, etc).  
     [0169] Referring now to FIG. 29 a , embodiments of a treatment algorithm using feedback control can include a patient determined/calibrated numeric pain/thermal scale  54   ps  for particular levels of energy delivery or levels of energy delivery combined with the delivery of a cooling medium. Numeric values can be assigned by the patients for levels of pain corresponding to particular amounts (e.g. joules)  54   ae  or rates (e.g. watts)  54   re  of energy delivery or amounts of energy delivery combined with a rate of delivery of a cooling medium  54   cr  (e.g. cc fluid/sec) having a selected temperature. Numeric values can be determined for sub-threshold pain tolerance levels, threshold pain tolerance levels, and over threshold pain tolerance levels. In an embodiment, a sub-threshold pain/thermal level can be assigned a value of one, a threshold pain/thermal level can be assigned a value of two and over-threshold level a value of three. An alternative embodiment can use a ten point scale (1, 5 and 10 for sub, at and post threshold levels, and/or any value in between) or any numeric range selected by the patient. In other alternative embodiments, the patient can select a color scale (for example white, green, red) to represent the levels of pain. In still other alternative embodiment the patient can select descriptive words (e.g. nothing, tingling, hurting, burning, excruciating, etc) to represent or indicate one or more levels of pain/thermal sensation. The patient can choose whichever means they find easiest to communicate their sensation of pain. The physician can have the patient try several methods (e.g. numeric, color, descriptive, etc) and then choose the method that has the greatest reproducibility for a given patient. Also in any of these embodiments, speech recognition and/or voice stress analysis software can be used to provide supplement information and analysis regarding the patient indicated level of pain. In such embodiments one or more components from such supplemental information can be coupled to the patients verbal description to enable a more reproducible indication of the patient&#39;s pain level.  
     [0170] In various embodiments, the pain and/or thermal calibration procedure can be done prior to initiation of the tissue treatment procedure and can be repeated at any time during the procedure to account for variations or treatment variables including without limitation, procedural, tissue site and patient variations. Also the calibration procedure can be performed utilizing energy delivery at a selectable tissue site  9  and can be repeated when a new site is selected to account for any site variation. Alternatively, the calibration procedure can be on a site that is physiological representative of the target tissue site and has equivalent pain sensitivity or at a selected site that has a greater or lesser pain sensitivity. Sights having greater sensitivity could include the fingertips, while reduced sensitivity sites could include skin on the back of the arms or the back itself.  
     [0171] In a various embodiments, a database  60   db  or mathematical model  60   m  can be utilized to calibrate or adjust the scale for pain/thermal sensitivities of different tissue sites or other treatment parameters. The mathematical model  60   m  or database  60   db  can be stored within device  54 ′ or  54 ″ or other logic resources  54   lr , memory resources  54   mr  or computer readable storage medium  54   sm . Examples of computer readable storage mediums include without limitation, floppy disks, magnetic tape, hard drives, ZIP drives, CD ROMs, ROMs, PROMs, EPROMs, ASICs and the like and other storage medium known in the art.  
     [0172] In various embodiments the model or database can be developed from a patient population database, a parametric database or data collected from each patient from a single treatment or multiple treatments or combinations thereof. The data can be collected during one or more calibration procedures described herein, over the course of an actual treatment or a combination of both. The model  60   m  can employ various numerical methods known in the art including linear interpolation, least squares, curve fitting, cubic spline and Newton Raphson fitting methods and the like and combinations thereof. As described below, database  60   db  can accessed or manipulated using database applications or programming language known in the art such as those available from the Oracle® Corporation (Redwood Shores, Calif.).  
     [0173] Referring now to FIGS. 29 a - 29   c  In various embodiments database  60   db  can be a relational database, an object oriented database, a programmable database, a network database, an Internet database, an analytical database, a hierarchal database, a meta-database or other database known in the art. Database  60   db  can also be configured to be coupled to other databases  60   db ′ including databases store on or coupled to the Internet or other distributed network  60   dn.    
     [0174] In an embodiment, database  60   db  can be a relational database configured to be programmed, queried, or updated using structured query language (SQL) known in the art. Accordingly in these and related embodiments, database  60   db  can include or otherwise be coupled to a database program module  60   dbm  which contains programs, or database applications known in art for performing one or more queries or other database operations known in the art. Module  60   dbm  be contained within the database or can be stored or embedded in logic resources  54   lr , memory resources  54   mr , device  54 ′ or device  54 ″.  
     [0175] In various embodiments database module  60   dbm  can also be configured to allow the user to enter, delete, or order, pool or otherwise manipulate data in the database. For example, the module can be configured to allow the user to select and utilize data for a single patient over a single treatment, data for a single patient over multiple treatments, data for multiple patients or data for an entire patient population. In this way, the user can adjust or fine tune the database for a given patient or procedure to obtain a more accurate and/or precise control of an energy delivery parameter or treatment controlled by the database. This fine tuning process can also be during the treatment process to dynamically modify the database during treatment. The database module can also be configured to allow the user to establish or change associations between one or more data elements, attributes or fields in the database such as pain/thermal sensation, delivered energy, an anesthesia dose, etc. Thus, the user can choose which particular treatment parameters to associate with a corresponding pain/thermal sensation level. In this way, the user can also fine tune or adjust the database to a particular treatment or patient to obtain more accurate and/or precise control of an energy delivery parameter or treatment.  
     [0176] In various embodiments database  60   db  can have different storage organizations or data structures known in the database arts. In an embodiment shown in FIG. 29 b , database  60   db  can have one or more records  60   dbr  which can include one or more data fields  60   dbf  which can include a first field  60   dbf ′ and a second field  60   dbf ″ used to store one or more data elements  60   de . First field  60   dbf ′ can be used to store a treatment parameter  60   tp  and second field  60   dbf ″ used to store a pain or thermal sensation level  60   ptl  correlated or otherwise associated with the treatment parameters  60   tp . In an embodiment, the database can configured to have multiple treatment parameter fields  60   dbf ′ associated with a single pain/thermal sensation level field  60   dbf ″ to allow for multi-variant or otherwise complex associations between treatment parameters and associated pain/thermal sensation or sensitivity.  
     [0177] In an embodiment shown in FIG. 29 c , database  60   db  can be a relational database known in the art having a table data structure where data elements  60   de  are stored in tables  60   t  having rows  60   r  and columns  60   c  which correspond to records  60   dbr  and fields  60   dbf . Table  60   t  can include multiple columns for storing pain or thermal sensation levels and one or more associated treatment parameters. In a related embodiment, database  60   db  can be an object oriented database having object tables  60   ot  consisting of objects  60   o  and attributes  60   a  which correspond to records  60   dbr  and fields  60   dbf . Attributes  60   a  can be used to store pain/thermal sensation levels and associated treatment parameters. In these embodiments database module  60   dbm  can be configured to support various relational and object oriented database methodologies known in the art.  
     [0178] In an embodiment a calibration procedure can be done to generate a database or model that correlates a pain or thermal sensation level to a particular energy delivery treatment parameter such as a power level (e.g. an RF power level) or a total delivered energy to a tissue site. In use, such a database can be configured to allow the medical practioner to utilize the patient&#39;s perceived pain or thermal sensation during an energy delivery treatment to more rapidly and precisely control the delivery of energy to a selected tissue site then would be possible without such feedback. Once the pain or thermal sensation level exceeds a certain threshold, system  54  or device  54 ′ can be configured to stop or decrease the delivery of energy to the tissue (or start increase the delivery of a cooling media) to preserve or otherwise protect non target tissue sites (e.g. an epidermal layer, sub-dermal plexuses) from unwanted thermal injury or damage. Other suitable energy delivery parameters that can be correlated with pain or thermal sensation levels can include without limitation, frequency of the energy source (e.g. RF, microwave, acoustical, etc.), wavelength of the energy source (e.g. optical wavelength), power waveform, duty cycle, current, heat transfer media flow rate, cooling media flow rate, fluid flow rate and the like. In an embodiment calibration procedures can be done to develop a database that correlates multiple energy delivery parameters to a pain or thermal sensation level or sensitivity.  
     [0179] In other embodiments, a calibration procedure can be performed to account for variations in pain/thermal sensation or sensitivity due to use of an anesthetic or other related medicaments. Again a database or mathematical model (using numerical methods described herein) can then be developed to calibrate or adjust a pain or thermal sensation scale for one or more anesthetic variables including without limitation, total dose, rates of delivery, delivery sites (e.g., topical, local, etc), delivery methods (e.g., bolus vs. continuous infusion), anesthetic types and combinations thereof. The model or database can also be configured to transform or convert a perceived pain or thermal sensation level for one dose of anesthetic, to that which would be experienced for another dose or when no anesthetic is used at all. The model could also employ the numerical methods described herein and/or pharmacokinetic models to account for one or more pharmacokinetic variations associated with the use of an anesthetic. For example, the model could be configured to account for variations in pain sensitivity due to changing levels of anesthetic at the tissue site or in the patient&#39;s body over the course of the treatment.  
     [0180] Embodiments of the invention can include one or more treatment algorithms that incorporate patient feedback into the treatment procedure. Example treatment algorithms are shown in FIGS. 30 and 31. The sequence of steps in these embodiments is exemplary and need not be sequence specific. Accordingly the order of steps can be varied, and one or more steps can deleted or repeated as needed by the physician. For example, microdermabrasion can be performed after administration of the anesthetic or the sedation step need not be done and the thermal/pain sensation scale developed without it. Other steps can also be added, for example re-treatment of a given site can be done based on other criteria such as degree of erythema, skin tension, or other physical characteristic or appearance.  
     [0181] Also while these algorithms use an RF energy delivery device and power sources, these approaches are exemplary and other energy delivery means and power sources are equally applicable to the algorithm including the use of dermatological lasers, microwave, ultrasound, infrared lamps, heat transfer fluids and combinations thereof all well known in the plastic surgery and medical instrument arts. Further, such energy can be applied topically, cutaneously or sub-cutaneously using surgical or minimally invasive surgical methods known in the art.  
     [0182] For laser embodiments, patient feedback can be utilized to achieve skin rejuvenation while preserving, at least in part, the epidermal layer and/or prevent burning, photocoagulation, or other injury to the epidermal layer or other non-target tissue. In a specific embodiment, an RF energy delivery device can be combined with the use of topical laser treatment either concurrently or in a pulsed duty cycle fashion. Suitable lasers can include, but are not limited to, any medical laser known in the arts including CO2 lasers, YAG lasers, dermatological lasers, flash lamp, pumped pulsed dye laser (585 nm), argon-pumped tunable dye laser (577 nm, 585 nm), copper vapor or copper bromide laser (578 nm).  
     [0183] In various embodiments, patient feedback can be utilized for performing a number of treatments of the skin and underlying tissue including, without limitation, epidermal remodeling and tightening, wrinkle reduction, elastosis reduction sebaceous gland removal/deactivation, hair follicle removal, adipose tissue remodeling/removal and spider vein removal and combinations thereof. The form and amount of patient feedback can be adapted for each of these particular applications. For example, the patient pain scale for sebaceous gland removal on the face can be set at lower level than for spider vein removal on an extremity. This can be done empirically or using a mathematical model  60   m  or database  60   db  described herein, to correlate feedback from one type of procedure to any number of procedures.  
     [0184] The use of one or more embodiments of patient feedback methods described herein can be adapted to be used with the tissue treatment procedures described herein as well as other dermatological and reconstructive or plastic surgical procedures known in the art. In various embodiments, feedback methods can be adapted for different procedures using site correlation or mathematical model approaches described herein as well use of a patient population database or an individual patient database generated during the course of one or more procedures.  
     [0185] In various embodiments, treatment levels can be titrated by using heat or pain perception signaling by the patient. Further, the patient&#39;s perception of pain or heat or physiological or biometric indicators thereof can be utilized to reduce or stop treatment or energy delivery so as to maintain temperature of non target tissue below an injury threshold level. In various embodiments, such injury threshold temperature can be 45° C. or lower, 42.5° C. or lower, 40° C. or lower or 37° C. or lower, or 35° C. This can be done by verbal communication to the medical practioner (via one or more of the pain/thermal scales described herein) or alternatively via biometric feedback coupled to the energy source or a feedback control system described herein (which may be coupled to the power source) or a combination of both verbal signaling and biometric feedback.  
     [0186] Several other examples of treatment algorithms and/or methods of using patient feedback are included herein (see Examples I-III), including treatment of eyebrows, jowls and forehead. In these and related embodiments, treatment levels can be titrated by using heat or pain perception signaling by the patient or by use of biometric measurement indications thereof. Areas having sub-threshold pain levels can receive additional treatment energy which can be in the form of additional passes by a skin energy delivery device. Contrarily, treatment can be stopped to areas producing a threshold pain/heat level. Also different perception levels can be used to titrate treatment for areas having differences in skin thickness and/or greater or lesser sensitivity to heat or pain.  
     [0187] Referring now to FIGS. 32, 33 a  and  33   b , in various embodiments, photographic or visual documentation of the tissue treatment site and surrounding areas can be utilized in one or more embodiments of the invention for treating tissue. Various methods of photographic or visual documentation can be configured to perform one or more of the following: (i) identify the target tissue site; (ii) quantitatively assess tissue treatment; (iii) qualitatively assess tissue treatment (iv) determine a treatment endpoint; (v) document a treatment endpoint; (vi) determine an amount of skin tightening; (vii) determine an amount of tissue remodeling; (viii) determine the need for repeat treatment; (ix) establish a patient population database for treatment at one or more tissue sites; (x), establish an image database of treatments at one or more tissue site; (xi) document a clinical or aesthetic result of a procedure; (xii) perform computer assisted modeling of a desired tissue shape or aesthetic result; and (xiii) perform computer assisted modeling of the tissue treatment procedure (e.g. direction of energy delivery application or number of passes of the energy delivery device of the tissue site) to achieve a desire result. An embodiment of an algorithm for performing photographic documentation is shown in FIG. 32. Again, the sequence of steps is exemplary and is not sequence specific. One or more steps may done in a different sequence or repeated as needed by the physician, nurse or other medical practitioner.  
     [0188]FIGS. 33 a - 33   b  show an embodiment of a method for image alignment for pre and post treatment images  80 ,  82  of target tissue site  9 . The pretreatment photo  80  can be pasted as a partial transparency over the post treatment photo  82 . This can be also done manually using a back illumination device (e.g., a tracing light or table) or electronically using an electronic photographic editor (an example being Photoshop®), to superimpose the post treatment image over the pretreatment image or vice versa. Anatomic landmarks  84  between the pre-treatment and the post-treatment photos/images  80 ,  82  can be aligned (with the exception of those of the treatment site). The treatment site  9  can then be visually assessed by the physician for degree of completion, skin tightening, remodeling, shape and the like. The assessment can also be done using optical projection or magnification devices as well as image analysis software known in the art to compare the two images to provide both quantitative (e.g. dimensional changes) and qualitative indications of the effects of a given treatment. In these and related embodiments the images can be displayed on a display device  402 , which can be integral to device  54 ′ or  54 ″.  
     [0189] Referring now to FIG. 34, an alternative embodiment of a method of to treat tissue to correct an aesthetic deformity  9   d  or redundancy  9   r  can include the use of a grid pattern  86  and a method for evaluating the predominant axis  9   a  of the deformity or skin redundancy. The predominate axis of the deformity can be determined and utilized to orient the grid pattern to most effectively correct the aesthetic deformity. The predominant axis can be determined visually, through dimensional measurement, or through computer determination using video imaging and spatial analysis software.  
     [0190] In an embodiment shown in FIG. 34, an oblong grid pattern  86   o  can be aligned along the principle axis  9   a  of the redundancy  9   r  or deformity  9   d . The grid pattern can consist of 1 cm 2  grid sites or other sizes larger or smaller depending on the tissue site. Specifically, the longitudinal axis of the grid pattern  86   la  can drawn on the skin treatment site  9  and the longitudinal axis of the grid pattern  86   la  is aligned with the principal axis  9   a  of the skin redundancy. An exemplary range of grids size include the range from about 0.1 to about 10 cm 2 , with other sizes and units (e.g. inches) also being equally applicable.  
     [0191] The alignment of the drawn grid pattern may be vertically for vertical skin redundancies, for example of the submental neck or oblique for a skin redundancy of the nasolabial fold. In the case of a vertical skin redundancy, more grid rows are drawn than grid columns. For a horizontally aligned skin redundancy such as the cheek, more columns are drawn at the treatment site than rows. For an equal skin redundancy in the vertical and horizontal dimensions, a square pattern grid with the same number of rows and columns is drawn. Depending on the type of the aesthetic deformity and the perspective of the observer, the medical practioner may reverse the pattern of grid orientation such that fewer rows or columns are drawn along the principle axis of skin redundancy.  
     EXAMPLES  
     [0192] Various embodiments of the invention will now be further illustrated with reference to the following examples. However, it will be appreciated that these examples are presented for purposes of illustration and the invention is not to be limited by these specific examples or the details therein.  
     Example I  
     [0193] Patient #1:  
     [0194] This patient was a 51 year old white female that had ptosis of the eyebrows and who desired a forehead thermoplasty. After following the patient treatment algorithm (PTA) with the application of EMLA, the grid pattern was applied to the forehead. The treatment was commenced in the glabellar region of the forehead between the eyebrows. Treatment levels were titrated by using heat perception signaling by the patient. Due to the thicker tissues of the glabella, levels 14.5 to 15.0 were required to produce a level 2 heat perception signaling by the patient. The lateral aspect of the glabella required less heat energy (14.5) than the medial glabella (15.5). The thinner soft tissues of the lateral superior forehead required treatment levels to be titrated down to 13.5 because of level 3 signaling by the patient. Areas signaled as heat perception level 1 were retreated at a treatment level that produced level 2 signaling by the patient. The glabellar region received a second pass at 14.5. Pre and post treatment photos were taken as per protocol. Immediate and visible raising of the eyebrows was evident.  
     Example II  
     [0195] Patient #2:  
     [0196] This patient was a 53 year old white female with ptosis of the eyebrows, especially in the lateral aspect. The patient had also undergone a bilateral upper blepharoplasty  3  years ago. She desired raising of her eyelids to further highlight the improvement in the appearance if her upper eyelids. Following the PTA with the application of EMLA, the grid pattern was applied to the forehead. Treatment levels were titrated up to level 14.5 in the glabella where level 2 signaling by the patient occurred. For the lateral superior forehead, titration down to 13.5 was required because of level 3 signaling by the patient. Grid areas that signaled with level 1 were retreated with treatment levels 14.5 in the glabellar region and 13.5 in the lateral superior aspect of the forehead. The photographic protocol with pre and post treatment photos was followed. The patient had moderate but demonstrable elevation of the eyebrows with improvement in the upper eyelids where a larger portion of the pretarsal segment was visible.  
     Example III  
     [0197] Patient #3:  
     [0198] This patient was a 53 year old male who was treated in the jowl area. Following the PTA with the application of EMLA, a 1 cm grid pattern was drawn on the left cheek area including the nasolabial fold and the lateral portion of the upper lip. The inferior aspect of the grid was extended to the mandibular margin. The treat level was titrated to up to 15.5on t6h inferior cheek area due to the thickness of the soft tissue. At this treatment level, patient signaling changed form a level 1 to a level 2. The superior portion of the cheek over the Zygoma and the infraorbital rim was titrated down to 14.0 to 14.5 because level 3 signaling occurred at 15.5. These tissues are significantly thinner than the lower cheek jowl area. A second pass on the jowl area was performed at 15.5. Significant demonstrable raising and flattening of the jowls, nasolabial folds with reduction of lower eyelid wrinkling was immediately evident.  
     CONCLUSION  
     [0199] It will be appreciated that embodiments of the invention presented herein are applicable to a wide variety of medical, dermatological and surgical procedures known in the art, including without limitation, reconstructive and plastic surgery procedures and minimally invasive procedures. It will also be appreciated that the foregoing description of various embodiments of the invention has been presented for purposes of illustration and description. It is not intended to limit the invention to the precise forms disclosed. Many modifications, variations and combinations within the scope of the invention will be apparent to practitioners skilled in the art. Also elements or acts from one embodiment can be readily substituted with elements or acts of another embodiment. Further, elements or acts from one embodiment can be readily recombined with elements or acts from other embodiments to provide further embodiments within the scope of the invention.  
     [0200] It is intended that the scope of the invention be defined by the following claims and their equivalents.