**4.3 Open neck, facelift approach**

In the patient for whom there is significant skin redundancy and laxity, an energy driven technology alone will be insufficient to achieve an optimal result. It has been the authors' experience, that best outcomes can be achieved when using the Renuvion™ handpiece in conjunction with a traditional open deep plane or SMAS face lift, neck lift approach. One may question why use the Renuvion™ handpiece at all if proceeding with a traditional facelift. Epidermal contraction was noticed by the authors when the Renuvion™ was used for ablative resurfacing. Consequently, the authors have speculated that similar tissue contraction can be achieved when the Renuvion is used in the subdermis. In the open facelift or neck lift, the skin has been fully released from the underlying platysma or SMAS, thereby completely releasing the fibroseptal network. In this situation, the energy is being targeted directly to the subdermis and not the fibroseptal attachments. When the Renuvion handpiece is being directly applied to the subdermis on an elevated skin flap, the authors have observed immediate contraction of the skin as seen in the figures above. The resulting shrink wrap effect permits less need for a vertical vector pull and less redundant skin to excise. Authors have found that the horizontal neck lines are less likely to be elevated into the lower cheek, and a smoother contour along the mandibular border is achieved. It was also noted that there is less skin to excise along the temporal anterior hairline creating well hidden incisions. For the open SMAS suspension face lifts, placing the handpiece along the jawline and medial jowl area creates a nice contraction and can obviate the need for a deep plane lift. It is not that a deep plane lift needs to be avoided, but this technique affords another option to the surgeon and patient.

#### **4.4 Ablative resurfacing**

The non-FDA approved application of the Renuvion™ for ablative resurfacing has been proven to be one of its most powerful applications. In the patient with significant rhytidosis and excess skin, wrinkle reduction and skin tightening can be accomplished with the Renuvion™ handpiece not seen with other technologies. Patients should expect significant downtime, which ranges from 10 days up to one month. As with most ablative resurfacing tools, this is not to be used in a Fitzpatrick skin type greater than 3 and even at times the Fitzpatrick 3 patient should be proceeded with caution. Thin skin should be treated on the pulse setting and results will not be as great. Diligent postop care is essential to the success of this treatment. Every patient experienced some milia and erythema, while some patients experienced hypertrophic scarring and hypopigmentation. The healing process may involve topical treatments such as tretinoin or adpalene, as well as laser treatments, kenalog injections and silicone sheeting to address minor complications.

The handpiece should be held no further than 5 mm from the skin in order to be effective. This is highly user dependent, requiring consistent, steady and constant movement across the skin surface maintaining uniformity in distance from the skin and speed of movement, moving at a speed of 1 cm/second [10]. Energy is being delivered directly to the epidermal surface, and therefore time on tissue is critical to achieve a good result and avoid complications. To accomplish wrinkle reduction and skin contraction, tissue coagulation and collagen remodeling needs to occur at the epidermis and epidermal/dermal junction just into the superficial papillary dermis. Delivery of energy into the deep papillary dermis or reticular dermis results in increased scar formation and hypertrophic scarring. For this reason, energy delivered, skin thickness, handpiece distance from the skin surface, and speed of movement are critical variables to outcome and reduced risk for complication.

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

The patient is prepped and draped in a meticulous sterile fashion. The skin is cleansed and degreased. Anesthesia is obtained, this can be accomplished using either systemic agents, sedation or with local anesthesia. If using local anesthesia, it is the authors' experience that a combination of local nerve blocks, mild tumescence and direct intradermal injections achieves best results. Selection of power setting depends on patient's skin type, skin thickness, and severity of wrinkles. The face is subdivided into zones of treatment. Number of passes and power settings vary based on zones of treatment (**Table 1**). Direction of movement of the handpiece, is optimally performed along the direction of the relaxed skin tension lines and it is the authors' opinion that this is less likely to result in hypertrophic scarring and potential webbing. While users have widely discussed ablative resurfacing using Renuvion™ with two passes at energies as high as 40%, the authors have found that satisfactory results can be achieved with one pass alone at 20% and less downtime. Early porcine studies performed by Bovie medical demonstrated the amount of tissue contraction using the BVX-044-BPS (now known as the Renuvion handpiece) is similar when comparing 40% power to 20% power, supporting the authors' opinion that optimal outcomes can be achieved at 20% [11]. The handpiece is held very close, within 5 mm of the skin and the endpoint looks similar to a toasted marshmallow (**Figure 7**). Continuous even movement is very important. Thin skin areas such as the upper and lower eyelid are treated at reduced energy


#### **Table 1.**

*The different settings in different areas of the face.*

#### **Figure 7.**

*The skin that is treated looks similar to a marshmallow that has just been exposed to the flame. Pre Renuvion measurement, Post Renuvion measurement.*

15–20% and only pass. Areas of deep rhytids in thick skinned patients such as the glabella or upper lip have been addressed at times with 2 passes at 20–30% energy and 4 L flow rates. As one approaches along the mandibular border the energy is reduced to 15% and wand distance from the skin is increased to defocus the energy and to reduce risk for hypertrophic scarring and forming a demarcation line. The user can also place the handpiece in pulse mode along the jawline which helps decrease hypertrophic scars. Pulsed mode should be considered for the thin skin lateral to the chin and medial to the MLF line because this skin has been noted to develop hypertrophic scarring.

As with other resurfacing modalities, treatment of the neck should be exercised with caution. However, nice results can be achieved at lower and fractionated or pulsed settings. The energy can be made fractionated by placing a meshed wet gauze on the skin and then firing the handpiece over the gauze or placed in a pulsed mode. This can be done on the neck or face for less of a result, but with faster healing time and a decreased risk of complications. When placing a head wrap on the patient, non adherent gauze is placed on the neck. No scarring has been noted with this treatment. However, the resurfacing must be defocused and fractionated. This affords the patient tightening of crepe like skin of the neck.

The machine now has a KJ counter which is helpful for both subdermal applications and ablative resurfacing, but this is not available when used in pulsed mode. Again, the exact energy that is best for the patient's skin type has not been determined.

#### **4.5 Post procedure care and normal sequelae**

The best start to post operative care starts before the procedure. It is essential that the patient has understanding and is prepared for the after care. Prior to surgery, sharing pictures during the healing phase will be helpful. Having detailed written instructions for subdermal and resurfacing cases is a must (**Figure 8**).

Subdermal neck and face procedures should wear a head wrap compression dressing for a few days and a head wrap at night for a few weeks which will help the skin contract and seal down to the underlying playtsmal muscle. The skin on the neck can look worse before it gets better similar to an elephant's foot. This typically settles down and can be improved with early treatment using IPL and non ablative lasers like Palomar 1540 XF. Delivery of energy to the subdermal neck is an intentional injury to the fibroseptal network, designed to stimulate collagen contraction. This resultant scar contracture can at times create tethering and bunching of the skin, particularly in the thin skinned patient. Dilute Kenalog 10 can help smooth out the skin during the healing process (**Figure 9**). The texture of the skin within a few weeks starts to improve. The thin crepe like skin will take longer and thick skin smooths out earlier. The platysmal muscle can create some bunching of the skin when it is overactive, so diluted neurotoxin can help smooth out the neck and hasten the healing process. Placing the handpiece too superficially or too long can cause a subdermal scar (**Figure 10**).

Resurfacing postoperative patients are very time consuming, require meticulous post operative care and must be seen frequently. During the first week, the regimen until re-epitheliazation includes washing with distilled water and a capful of vinegar and/or mild soap (vanicream or cerave) twice a day. It is very important to tell the patients to not remove the eschar or dead skin while washing and to leave it as a biological dressing. The authors have found that constant picking and rubbing will cause prolonged redness and itching, and increases the risk for hypertrophic scarring or hypopigmentation (**Figure 11**). Keeping the treated area moist and protected with aquaphor/vaseline or an occlusive silicone patches can help the process of epithelialization. Informing the patient that they may need to frequently change

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

#### **Figure 8.**

*This patient is two weeks postop. She did not have any sequelae or complications from the resurfacing procedure. This redness and splotchy circular healing the authors have found is completely normal and fades slowly.*

#### **Figure 9.**

*This patient has some indentation and elephant looking edema along the jawline which dissipated with time and the use of IPL.*

their skin care for resurfacing cases will be necessary. All patients are different and with the new skin they can have issues with dermatitis.

After epithelialization, several different sequelae can occur. Most have intense itching after two weeks and hydroxyzine works well to temper this. The hyperemia can be problematic and is worse after a shower or working out. This can improve with frequent IPL treatments and skin care. The redness seems to fade into circles

#### **Figure 10.**

*This thinned skin patient had a subdermal scar after placing the wand too close to her dermis. This required IPL, 1540 XF, PRP injections and filler injections to resolve this indented scar.*

#### **Figure 11.**

*This patient suffered from redness and hypetrophic scars from too much mechanical irritation. Her scars developed 6 weeks post and were treated with IPL, 1540 XD, 1540 XF, injections of Kenalog 10, 5-FU, and PRP. The scarring has improved, but she has several permanent hypopigmented areas.*

similar to a cheetah print. Most patients wake up after after 3 to 4 weeks and notice that the pattern has disappeared. Development of milia is common and frequent extractions may be necessary. Differen gel and Epi-duo can also help with the small white heads and milia that develop. This typically resolves after about 8–12 weeks.

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