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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_511_Библиотеки_им_академика_М_И_Перельмана
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290
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E. Akkary
a
b
c
Shaft Diameter:3mm
APYX PLASMA/RF
HANDPIECE
st
1
indicator line 4mm
3 mm diameter shaft
Rounded (bullet shaped) tip
360° side firing
15 & 27 cm length
Ergonomic (thicker) handle
Single Use / Disposable
Indicator lines identify distance between
incision port and tip
Split grounding pad MUST be used
Indicator lines to show
distance to tip
Rounded Tip
Fig. 18.5 (a, b, and c) Types of handpieces (short is 15cm, long is 27cm). (Courtesy of Apyx Medical Corporation (Apyx Medical Corporation
owns the copyright of this image))
from tip
“Side Firing”
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Fig. 18.6 Activation of the handpiece
18.4 Technique forSubdermal Renuvion®
Treatment
Renuvion® has many advantages including ease of use, short
learning curve, and speed of treatment. It is very important to
follow proper techniques to avoid complications and optimize patient’s safety and results.
• Access site placement for Renuvion handpiece generally
follows the basic principles of access for liposuction
cannulas.
• However, it is important to understand that while cross-
hatching is routinely used in liposuction, this is not necessarily the case with Renuvion®.
• Crosshatching with Renuvion increases the energy deliv-
ered to the tissue. Therefore, this technique can be implemented based on the desired goal of the treatment, but
caution must be exercised to avoid thermal injury to the
skin and scarring.
• Incision site measures at least 5mm to allow for the intro-
duction of the handpiece without compromising the skin
at the incision site and to allow for helium escape after
treatment decreasing crepitus.
• Renuvion is used in the subdermal plane. Some practitio-
ners use it externally, which is an off-label use.
• Tumescence anesthesia is used to inltrate the surgical
planes prior to treatment.
• Since the radiofrequency energy is carried on helium
plasma ow, it is important for the tissue to be tunneled
prior to treatment. If the procedure is done with liposuction then it is expected that this had already been achieved
by completion of liposuction prior to Renuvion®
treatment.
• If no liposuction is involved, then tunneling needs to be
done using a disruptor cannula of, at least, 4 mm
diameter.
291
• The manufacturer does not recommend using the handpiece for tunneling.
• Prior to treatment, the handpiece should be primed by
activating it near a metal object, for example, an Adson
forceps. Once the plasma beam is visualized traversing
the end of the probe to the metal object, the handpiece is
now activated.
• Generally, in my practice, I use the following settings:
– 80% power for tissue below the clavicle
– 60% power for tissue above the clavicle
– Helium ow at 2L/min.
• These settings are general guidelines only and need to be
adjusted according to the treatment area.
• For example, a thin supercial treatment area with sparse
subcutaneous tissue might need lower settings to avoid
skin injury.
• The following steps summarize the treatment technique
after placement of the handpiece into the subdermal
plane:
– After introducing and positioning the handpiece
against the subdermal plane, withdraw the handpiece
approximately 2 cm before activation to avoid skin
injury.
– Activation of the handpiece should be done while it is
being withdrawn and pulled back toward the handpiece access skin incision.
– Stop activation approximately 2cm from the skin inci-
sion to avoid skin injury.
– The speed of withdrawing the handpiece, while acti-
vated, should be 1–3cm/s.
– One treatment while withdrawing the handpiece is
called a “stroke.”
– Multiple strokes should be done to cover the treatment
area, strokes should be 3cm apart at the initial point of
activation (the distal part of the treated area).
– Strokes in one plane are called a “pass” (Fig.18.7).
– Deep, intermediate, and supercial passes are com-
monly used except if the tissue is too thin, then only
supercial passes may be used. Avoid bending the
handpiece or tenting the tissue.
– It is important to check the blade of the handpiece dur-
ing treatments as tissue build-up can occur decreasing
the efcacy of treatment. This issue will cause an F13
error to display on the generator (Fig. 18.8). If this
occurs, it needs to be gently brushed of the blade. Use
a gauze or soft brush, avoid using metal instrument or
scratch pad.
– After treatment, massage the tissue toward the incision
sites to help get rid of the helium and decrease postop-
erative crepitus. You can also execute aspiration with a
liposuction cannula to eliminate the gas.
– Contouring compression garment is used
postoperatively.
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Fig. 18.7 Strokes and passes. (Courtesy of Apyx Medical Corporation (Apyx Medical Corporation owns the copyright of this image))
18.5 Short Discussion About Treatment
Modalities
Renuvion® represents an excellent and efcient tool for
helium plasma and radiofrequency-based skin tightening. It
is important to understand that the FDA clearance is a general clearance for medical use in soft tissue cutting, coagula-
tion, and ablation and is not specic for skin tightening of a
certain body part [1]. This is important to discuss with the
patients before the procedure and it is also important to
understand as the specic use for skin tightening or skin
resurfacing would be considered off-label.
Off-label use is a term commonly misunderstood by the
public and even healthcare workers to the extent that some
think that off-label use is a synonym for illegal use. It is
imperative to recognize that off-label use of a medical device
is legal per the Federal Food, Drug, and Cosmetic Act which
states that medical professionals can administer any
approved, legally marketed medical device and can prescribe
or administer that device for off-label use. Similarly, the
1997 FDA Modernization Act permits FDA cleared devices
to be used off-label [2]. The term off-label refers to any use
that was not listed in the company’s application to the
FDA.Therefore, if the company does not specify in the FDA
application of the device that said device is used for “skin
tightening” then using it for skin tightening would be off-
Fig. 18.8 F13 error. (Courtesy of Apyx Medical Corporation (Apyx
Medical Corporation owns the copyright of this image))
label. A simple example to put things into perspective, botulinum toxin neuromodulator was approved by the FDA for
Illustration Courtesy of ApyxTM Medical
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293
the treatment of the glabella but has been used for other areas
as crow’s feet, forehead, and platysma. Using the neuromodulator in these areas would be considered an off-label use.
18.6 Details ofTreatment Modalities
The radiofrequency energy created by the generator travels
into the handpiece energizing an electrode over which the
helium gas passes over creating the helium plasma. The ionization and neutralization of helium generate heat energy
that reaches the tissue via the plasma beam (Fig.18.9). Also,
radiofrequency energy reaches the tissue adding to the delivered heat [3]. Renuvion causes rapid heating then sudden
cooling of the tissue where the tissue temperature reaches
85°C in 0.04–0.08s followed by instant cooling [4]. Duncan
reported that 1min of Renuvion® activation delivers 1kJ of
energy [3].
18.6.1 Renuvion Treatment Can BeClassied
Into
18.6.1.1 Subdermal Treatment
Renuvion may be used for skin tightening using tumescence
anesthesia with or without liposuction. Different areas of
applications commonly include the jawline (Fig.18.10), submental region (Fig.18.11), posterior arms, trunk (Fig.18.12),
and upper medial thighs.
One of the key points to achieve good tissue response and
proper results with Renuvion® is to assess tissue thickness
and depth. The thicker the treatment area is, the higher power
and more passes are needed and vice versa. For example,
treating submental region and jawline represents an area
with thin skin and no signicant amount of subcutaneous tissue as compared to the trunk. So, when treating the submental region and jawline, I generally keep the power setting at
60% with helium ow of 2L/min and based on the thickness
of the tissue I perform 1 or 2 passes only. It is very important
to avoid crosshatching in this area as this can cause thermal
injury and disguring scarring of the neck. Staying in the
supercial subdermal plane is essential to avoid injury to the
marginal mandibular nerve. It is important to keep in mind
that thinner areas need less power and lower ow to avoid
Fig. 18.10 Treatment of jawline (postauricular access)
Fig. 18.9 Formation of
helium plasma beam.
(Courtesy of Apyx Medical
Corporation (Apyx Medical
Corporation owns the
copyright of this image))
SOLID LIQUID
Melting Vaporization
ENERGY
LOW HIGH
GAS PLASMA
Ionization
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E. Akkary
Fig. 18.11 Treatment of submental region (submental access)
overzealous treatment. It is reasonable when treating areas
with thin layer of body fat to decrease the power to 60 or
65% and decrease the ow to 1.5L.
18.6.1.2 Epidermal Treatment (Resurfacing)
This is an off-label application for Renuvion that might help
achieve results close to CO2 laser resurfacing in some
patients. Small volume of tumescence anesthesia is injected
into the treatment areas. Here, the settings tend to be more
conservative than the subdermal treatments.
The short handpiece is used externally applying the
plasma beam directly to the epidermis. This can be implemented to resurface rhytids, solar damage, and tighten the
skin in different areas of the face including midface, nose,
glabella, forehead, perioral and periocular regions.
The settings are usually kept between 20–40% with
helium ow 1–2L/min. It is important to keep in mind that
this is an off-label use and patient needs to understand what
Fig. 18.12 Treatment of the trunk
this means and sign an informed consent indicating that
resurfacing is an off-label use. I also recommend obtaining
documentation from your professional liability carrier indicating coverage of off-label use as some insurance companies do not provide this coverage.
Technique for facial resurfacing is summarized into the
following steps:
1. The face is prepped and draped in the standard surgical
fashion.
2. Anesthetic eyedrops are used and nonconductive corneal
shields are placed.
3. Tumescence is prepared using lidocaine at 0.05% concentration and epinephrine at 1/500,000 concentration.
4. Tumescence is then injected into the treatment areas
using 25-gauge needle on a syringe.
5. Proposed tumescence volume is 50mL for the forehead,
50mL for each malar region, 10mL for each periocular
region, 20mL for the perioral region, 20mL for the nasal
area, and 20mL along the jawline on each side.
Before After
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295
6. The settings are usually kept between 20 and 40% with a
helium ow 1–2L/min. For the periocular area, I recommend keeping the settings at 20% power and helium ow
at 1L/min.
7. Treatment is usually achieved by 1–2 passes.
8. Use wet saline gauze between passes to remove the eschar
and hydrate the skin.
9. Silicone occlusive dressing (Silon) is then applied (Bio
Med Sciences, Bethlehem, PA, USA).
18.7 Complications
Complications specic to Renuvion® treatment include:
1. Swelling and ecchymosis are usually self-limiting and
can be expected in a normal postoperative course.
2. Asymmetry.
3. Skin irregularities.
4. Disguring scarring.
5. Skin burns.
Whether subdermal or epidermal treatments are applied,
it is advisable to err on the conservative side. Avoid aggressive treatment to decrease risk of scarring, irregularities, and
burns. It is important to keep in mind the errors that can lead
to serious complications and avoid them. These can be summarized as follows:
1. Setting the power of the generator too high.
2. Setting the helium ow too high.
3. Inadequate tumescence anesthesia.
4. Inadequate tunneling.
5. Activating the handpiece while advancing it through the
tissue or activating it while it is not in motion. The handpiece should be activated only on withdrawal continuous
motion.
6. Crosshatching the passes in a thin area.
7. Performing too many passes in the same area.
8. Activating the handpiece against the skin in resurfacing
or the dermis in subdermal treatment. The handpiece
should be 2cm away from the tissue prior to activation.
9. Keeping the handpiece activated close to the skin incision while withdrawing the handpiece. The handpiece
should be deactivated 2 cm away from the skin
incision.
10. Using alcohol-based prep. This represents a re hazard
with Renuvion®.
11. Having oxygen owing to the operative eld. This also
represents a re hazard with Renuvion®.
18.8 Preoperative andPostoperative
Pictures
18.8.1 Two Months After 360-Degree Trunk
Liposuction Using Vaser withRenuvion
• The upper and lower abdomen were treated using the following parameters:
– Power: 80%.
– Helium ow: 2L/min.
– Passes: Supercial, intermediate, and deep (3 passes
from each access point with crosshatching).
• Even though, it takes approximately 6months before
seeing the final results, significant improvement in
skin turgor is very noticeable only 2 months after
surgery.
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Before
Before After
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18.8.2 Two Months After Submental
andJawline Vaser Liposuction
withRenuvion
E. Akkary
• The submental area and jawline were treated the follow-
ing parameters:
– Power: 60%.
– Helium ow: 2L/min.
– Passes: Supercial, and deep (2 passes from each
access point without crosshatching).
• Even though, it takes approximately 6months before see-
ing the nal results, signicant improvement in skin tur-
After
gor, jawline contour, and cervical mental angle is very
noticeable only 2months after surgery.
18.8.3 Two Months After 360 Degree Vaser
Trunk Liposuction withRenuvion
• The upper, lower abdomen, and waistline were treated
using the following parameters:
– Power: 80%.
– Helium ow: 2L/min.
– Passes: Supercial, intermediate, and deep (3 passes
from each access point with crosshatching).
• Even though, it takes approximately 6months before seeing the nal results, signicant improvement in skin turgor is very noticeable only 2months after surgery.
Before After
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18.8.4 Two Weeks After Liposuction
withRenuvion Treatment ofSubmental
Area andJawline (No Vaser WasUsed
inThis Case)
297
• The submental area and jawline were treated the follow-
ing parameters:
– Power: 60%.
– Helium ow: 2L/min.
– Passes: Supercial, and deep (2 passes from each
access point without crosshatching).
• Even though, it takes approximately 6months before see-
ing the nal results, signicant improvement in skin turgor, jawline contour and cervical mental angle is very
noticeable only 2weeks after surgery.
18.9 Discussion andPearls ofWisdom
Renuvion® represents one of the best technologies to date in
skin tightening. I expect the applications of Renuvion® to
keep expanding as we obtain more data and share techniques
and outcomes.
The role of heat and skin tightening is well established in
the cosmetic surgery literature. Renuvion® offers many
a
advantages when used for skin tightening including ease of
use, short learning curve, time efciency, and rapid cooling
of the tissue. This last feature gives us the advantage of not
needing extra equipment and monitors to measure the skin
temperature.
Renuvion achieves the goal of skin contraction by rapid
heating of the tissue to 85°C and then rapid cooling with the
helium ow. This unique mechanism attains subdermal collagen contraction of approximately 40–50% while
decreasing the possibility of thermal injury [1, 5, 6]. The
mechanism of action of Renuvion targets one of the most
important signs of aging, which is weakening of the broseptal network (FSN).
This network extends from the muscle layer to the skin
acting like ligaments that keep the skin tight and smooth.
Weakening and laxity of the FSN over time lead to skin laxity. Renuvion improves skin turgor not only by tightening
and contracting the FSN bers but also by stimulation of
neocollagenesis and remodeling of the dermal matrix [7]
(Fig.18.13).
b
Fig. 18.13 Fibroseptal network (FSN) being treated by (a) old handpiece (b) new handpiece. (Courtesy of Apyx Medical Corporation (Apyx
Medical Corporation owns the copyright of this image))
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E. Akkary
The most common settings for subdermal treatments are
between 60 and 80% power with 2L of helium ow per minute. Duncan reported that in these settings, the maximum
change in skin temperature does not exceed 4°C from the
baseline skin temperature [8].
Renuvion® represents a safe, effective, and easy to use
technology with multiple applications in cosmetic surgery.
Following standard guidelines, proper techniques, and safety
measures help optimizing the outcomes while decreasing the
possibility of adverse effects.
References
1. https://www.accessdata.fda.gov/cdrh_docs/pdf19/K191542.pdf.
2. https://www.fda.gov/.
3. Duncan DI.Helium plasma-driven radiofrequency in body contouring. In: The art of body contouring. 2019. https://doi.org/10.5772/
intechopen.84207.
4. Paul M, Mulholland RS.A new approach for adipose tissue treatment and body contouring using radiofrequency-assisted liposuction. Aesthetic Plast Surg. 2009;33:687–94.
5. Gentile RD. Renuvion/J-plasma for subdermal skin tightening
facial contouring and skin rejuvenation of the face and neck. Facial
Plast Surg Clin North Am. 2019;27:273–90.
6. Vangsness CT Jr, Mitchell W 3rd, Nimni M, Erlich M, Saadat V,
Schmotzer H.Collagen shortening. An experimental approach with
heat. Clin Orthop Relat Res. 1997;(337):267–71.
7. Kim M, Kim KE, Jeong SW, etal. Effects of the ultra-high-frequency
electrical eld radiofrequency device on mouse skin: a histologic
and molecular study. Plast Reconstr Surg. 2016;138:248e–55e.
8. Duncan D.Optimizing tissue interaction with helium driven plasma
plus radiofrequency using a porcine model. In: 2019 American
Society for Laser Medicine and Surgery Annual Conference, 30
Mar 2019.
Part V
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Abdominoplasty
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