**Abstract**

Energy based devices have been developed for the purposes of tissue contraction and skin tightening. Its application in the face and neck have been explored using lasers, temperature controlled monopolar and bipolar radiofrequency, and ultrasound. The purpose of this chapter is to explore the various applications for the face and neck using Renuvion™, a unique energy driven device based on plasma generated from the combination of helium gas and radiofrequency energy. The advantage of this technology is its ability to offer precise delivery of heat to tissue with minimal thermal spread, in part due to the rapid cooling aided by the helium gas. We will explore the options in which this technology can be incorporated to rejuvenate the face and neck, the patient selection considerations in choosing method of approach, surgical technique, anticipated outcomes, potential concerns and or complications associated with this and expected perioperative care. Applications in the face and neck include: (1) Subdermally in the neck as a stand alone procedure with or without liposuction. (2) Subdermally in a limited incision, non-excisional technique with a concomitant platysmaplasty either with an open approach or percutaneous use of suture suspension for the platysmal muscle. (3) Subdermally in conjunction with an open traditional rhytidectomy involving skin excision. (4) Ablative resurfacing—fractional or pulsed and full continuous modalities (non-FDA cleared at the time of this writing). It is the authors' experience that with appropriate patient selection this can be a powerful tool that can deliver skin tightening and rhytid reduction not seen by other technologies available.

**Keywords:** skin tightening, facelift, necklift, helium plasma, renuvion, facial rejuvenation

### **1. Introduction**

The aging population is on the rise in the United States, with greater than 30% of the US population being over the age of 50 based on 2019 demographic data [1]. Traditional facelifting has largely been the gold standard for facial rejuvenation to address skin laxity in the face and neck. Energy based devices have emerged in the past several years as a treatment alternative to manage skin laxity either as a standalone procedure or used concomitantly with open surgical techniques [2]. The aging and the youth are looking for alternatives to traditional surgeries to improve their appearance. These devices can help tighten the skin and diminish subcutaneous fat with presumed less downtime, smaller incisions or less visible stigmata of having had surgery.

The normal body temperature is 37°C, at 50°C cell death begins over a 6 minute period [3] and at 60°C cell death occurs instantly [4]. At temperatures between 60° and 100°C, protein denaturation and coagulation occurs in conjunction with cell death, it is these two processes that results in tissue contraction and cellular regeneration [3]. Collagen is the primary protein in the skin and subdermal fibroseptal network. Denaturation of collagen begins at 66.8°C [5] resulting in rapid contraction by up to 1/3 of the collagen fiber length [6]. Furthermore, thermal injury initiates a wound healing response that results in neocollagenesis which can occur over 6 months. The Renuvion™ handpiece is a novel technology that uses helium plasma to achieve temperatures of 60–80°C in 0.08 to 0.04 seconds for maximum tissue contraction with subsequent rapid cooling reaching temperatures below 65°C within 0.1–0.2 seconds to reduce risk for thermal spread or collateral injury. In its subdermal applications, maximum change in external skin temperature was less than 4°C [7]. These unique thermoplastic properties allow for maximum tissue contraction and skin tightening with reduced risk for collateral injury. In applications of the head and neck, this is highly operator dependent and an understanding of how tissue contraction occurs is important in achieving optimal results whether it is used for a subdermal treatment or a resurfacing treatment.

The Renuvion handpiece is particularly appealing because it can be used in multiple applications. The subdermal technique can be used as a standalone treatment or be paired with a traditional facelift, while the ablative resurfacing produces unparalleled wrinkle reduction and skin contraction. Choosing optimal candidates is key. A patient seeking wrinkle reduction as well as achieving lift may be an excellent candidate. However, particularly with the ablative resurfacing technique, if the patient is unwilling to accept the downtime of 10 days to a month, there may be alternate options with less recovery time. It is also important to consider a patient's Fitzpatrick skin type and avoid this treatment for skin types greater than 3. Patients with type 3 should be treated with caution considering the risk of hypopigmentation. In addition, thin skin should be treated on the pulse setting, and the results will not be as significant as with thick skin.

#### **2. Our evolution**

It is first inherently important to understand this single device has two completely unique and distinctly different applications. One being used as a tool for subdermal "minimally invasive" skin tightening. This can be used in conjunction with other technologies such as liposuction with or without energy driven assistance (i.e., Vaser™), an open platysmaplasty or a limited incision/percutaneous suture suspension platysmaplasty such as MyEllevate™ to achieve optimal results of tightening the neck and jawline. In this technique, the energy is being delivered to the subdermis and fibroseptal network to allow the skin, subdermis and underlying fibroseptal network to contract en bloc uniformly to tighten and improve the neck and jawline. This is very patient dependent and not all patients get the same tightening without removal of skin.

The second, non-FDA approved, usage of this machine is the most powerful. It was noticed by many that wrinkle reduction with ablative resurfacing using Renuvion™ is wildly successful. The results can be profoundly amazing, but it is far from "minimally invasive". The authors found that not only did resurfacing result in dramatic wrinkle reduction, but a significant contraction of the skin along the jawline, eyelids, forehead and upper lip was noticed as well. The degree of skin contraction in many cases matched that of outcomes seen in surgical procedures involving skin removal—such as that of a blepharoplasty in the eyelids (**Figures 1** and **2**).

*Applications of Helium Plasma in Rejuvenation of the Face and Neck DOI: http://dx.doi.org/10.5772/intechopen.100162*

#### **Figure 1.**

*One year after full face renuvion resurfacing, this patient's aged elongated upper lip was contracted that it almost restored the 1/3's proportions of the face.*

#### **Figure 2.**

*This patients' mid face and upper lip had elongated with the aging process and sun, full face Renuvion™ resurfacing shortened the cutaneous upper lip significantly. The pink portion of her lip was rotated outward lifting her vermilion border while also decreasing her lip lines. This is a one year postoperative picture.*

Again, this technique is highly operator dependent which will be discussed in detail later in the chapter.

Noticing the degree of skin contraction that can be achieved with ablative resurfacing and delivering energy directly to the epidermis, the authors questioned whether similar results could be achieved by delivering energy directly to the subdermis when it was separated from the fibroseptal network. In an open facelift technique, wherein the skin flap is fully elevated and released from the underlying fibroseptal network, energy is delivered directly to the lifted skin and subdermis. The Renuvion™ handpiece is now used in every open facelift that involves excision of redundant skin in conjunction with a platysmaplasty, deep plane or SMAS suspension. Previously, when performing a deep plane lift in the patient with excessively redundant skin, the vector of elevation results in significant skin removal and a significant shift of existing horizontal neck lines into the cheek and excess skin

#### **Figure 3.**

*(A-D) This intro-operative picture shows the excess skin with the neck flap is lifted inferiorly and superiorly. The Renuvion™ handpiece was used directly on the subcutaneous lifted flap and dermis. Approximately 6 passes were performed along the entire skin flap. Lifting the skin flap after the Renuvion™ had tightened the flap demonstrating the amount of skin contraction that can be achieved.*

#### **Figure 4.**

*This patient had an extended SMAS facelift on one side because she had a neck dissection 5 years earlier on the left side. The Renuvion™ was used subdermally to contract her skin in hopes to create a more symmetric look due to the previous dissected and irradiated neck skin on the left. The pictures shows preoperative, 6 months post op, and 2.5 year post op demonstrating the longevity of the skin contraction.*

removal in the temporal area. With the use of Renuvion™ there is up to 1 to 1.5 cm of skin contraction seen directly on the table allowing less skin removal upon redraping (**Figure 3**). An improved shrink wrap effect is seen along the jawline without abnormal shift of the lower horizontal neck lines. There is longevity to this skin tightening, patients seen at 3 years follow up have maintained results without further need of touch up, tuck ups at the submental area or jawline (**Figure 4**).
