**8. Case selection**

The following cases illustrate the effectiveness of Renuvion® technology in patients with compromised skin quality and soft tissue gliding planes because of weight fluctuations and aging. Patients were considered good candidates as they had no prior surgeries or energy-based treatments in the proposed treatment areas, desired improvements in soft tissue laxity without excisional scars, and demonstrated mild pendulosity that was felt could notably improve with the expected 30% contraction. Benefits were seen in the treatment areas of the upper arms, back bra rolls, and abdomen. The topography for liposuction and tightening was marked preoperatively in the upright patient. Portal sites were planned to permit crisscross patterns, pre-tunneling with LASER or VASER® and liposuction cannulas, allow easy strokes with the Renuvion® handpiece, as well as ventilation of residual helium gas. Sterile prep and drape with induction of general anesthesia followed. Tumescent solution utilized in all patients was composed of 1 Liter NaCl solution with 25 ml of 1% Xylocaine and 1 cc epinephrine. Residual gas was always aspirated. No worrisome clinical adverse effects such as skin compromise, erythema, etc. were seen. The patients minimized activity and used ice packs intermittently for edema control the first few days. Each was placed in postoperative compression garments for 6 weeks minimum. No unexpected sequalae were seen, including skin necrosis, seroma, fibrosis, altered sensitivity, portal burns, infection, dyschromia or long- lasting contour irregularities. Patients reported little tenderness postoperatively. All patients were pleased with their outcomes.

**Figure 1** shows a 39-year-old woman who underwent a large amount of fat removal from each arm that contoured well with adjunctive Renuvion® treatment of residual laxity. She was a G1P0, nonsmoker, who had undergone an 85 lb. weight loss following gastric sleeve operation 4 years prior. She presented with a desire to reduce her arm sizes. Her current BMI was 33.08. She demonstrated grade 3 inner arm ptosis and laxity with more fat in the distal one third of each arm. She did not demonstrate axillary or forearm ptosis. She desired contouring but refused the excisional scars of brachioplasty. She demonstrated severe arm laxity but reasonable skin quality with good skin turgor, no striae nor fine wrinkling and had moderate adiposity in both proximal and distal arm regions. She was felt to be a good candidate with reasonably adherent soft tissue, suggestive of a more robust fibrous septal network substrate to target and contract with the RF helium plasma stream. A total of 700 cc tumescent solution was infused into each arm, followed by VASER® application. The 5-ring probe was used for uniform acoustic energy distribution, providing 10% energy dispersion from the 3.7 mm probe tip, and 90% from the sides. It delivered ultrasonic

**Figure 1.**

*(a) Patient presented with excess inner arm subcutaneous fat, laxity and grade 3 inner arm ptosis, and (b) pleasing contours are seen 3 months following VASER® and Renuvion® assisted liposuction.*

#### *Contractile Effects of Radiofrequency Energized Helium Plasma on the Fibrous Septal Network DOI: http://dx.doi.org/10.5772/intechopen.97849*

energy in pulsed fashion for added safety at 70% energy levels for 7 minutes in each arm. Next, a 3 mm multi-directional liposuction cannula was utilized to remove 700 cc from the right upper arm and 575 cc from the left arm, nearly circumferentially. Renuvion® was then primed and the blade retracted. The handpiece was introduced and activated upon withdrawal through multiple tissue depths subdermally and deeper near Scarpa's fascia. Tissue was gathered around the handpiece to increase uniformity, and 6 multi-depth passes were completed in a radial fashion at an approximate speed of 1 cm/sec, 70% power, with 3 L/min helium gas flow. The set of 6 passes was completed in tissue areas that were 15 cm from the port radially.

**Figure 2** shows a 40-year-old woman with minimal rectus diastasis and adiposity who obtained improved abdominal appearance with the use of Renuvion® subdermal coagulation. She demonstrates longevity of effect 2 years post-op. She was a G2P2, nonsmoker who experienced 50 lb. weight fluctuations with each pregnancy. At presentation 5 years postpartum, her BMI was 20.05 and she did not have a C section scar or tissue overhang, thereby making her a suboptimal candidate for traditional abdominoplasty. Since the abdomen has more fibrous septal network bulk to recruit, it was felt that the predictable fibrosis, remodeling and collagen contraction offered by Renuvion® subdermal coagulation could offset any exacerbation of laxity from liposuction. A total of 750 cc tumescent solution was infiltrated between the upper (above the umbilicus) and lower (below the umbilicus) abdomen, and 250 cc into each hip and waist area bilaterally. The VASER® was utilized at 60% power in pulsed mode until there was no resistance. Liposuction was completed with 50 cc lipoaspirate from the upper abdomen, 150 cc from the lower abdomen, and 100 cc from each hip and waist bilaterally. Next, the Renuvion® handpiece was set at 60% power, 2 L/min gas flow and 6 passes were completed in a radial fashion at 1 cm/sec. This was done in the upper abdomen, repeated in the lower abdomen, and each waist and each hip, 15 cm from the ports in all directions. Again, tissue was gathered with the non-dominant hand to increase uniformity and treat tissue at different depths. She demonstrated contraction as early as one week, and a two year progressive improvement, purportedly from new collagen ingrowth within the connective tissue stroma.

#### **Figure 2.**

*(a) Patient presented with minimal abdominal subcutaneous fat and skin laxity, and (b) pleasing contours are seen 2 years following VASER® and Renuvion® assisted liposuction.*

**Figure 3** shows a 63 year old woman with marked skin laxity, poor skin quality and little adiposity throughout the arm, forecasting a poor result to traditional RF technologies. She obtained pleasing tissue contraction following Renuvion® subdermal coagulation. She was G3P2, nonsmoker with grade 3 inner arm ptosis and BMI of 20.50. She too desired improvement in her arm contours but refused brachioplasty. She did not have axillary or forearm ptosis. It was plausible that older skin contours would result as laxity would prevail following any fat removal without thermal contraction. She too would not accept lengthy brachioplasty scars and was willing to proceed with Renuvion® subdermal coagulation. The approach included near circumferential discontinuous soft tissue release, liposuction, and delivery of Renuvion® for subdermal coagulation of the superficial fascial system and was able to provide good contouring. A total of 25o cc of tumescent solution was infused into each arm, followed by VASER® application. The 5 ring, 3.7 mm VASER probe was utilized at 60% power in pulsed mode, for 2 minutes in each arm. The 3 mm multidirectional liposuction cannula removed 125 cc of fat from each arm. Given her thin skin, little adiposity, and probable minimal target fibrous substrate, Renuvion® energies were reduced to 50%, 4 lpm gas flow and 6 passes were completed in all directions for 15 cm from the port. Similar to the other patients, the tissue was gathered and the handpiece speed of 1 cm/sec was maintained. End hits were avoided by remaining deep and maintaining constant handpiece motion.

**Figure 4** shows a 59 year old woman with marked laxity and curtaining of back tissue that achieved significant improvement following treatment with Renuvion®. She was a G3P2, nonsmoker who had undergone an 85 lb. weight loss following a gastric sleeve operation 3 years prior. At presentation, her BMI was 32.92. A total of 750 cc of tumescent solution was infiltrated into each waist, hip, and bra roll area bilaterally. The VASER® 5 ring, 3.7 mm probe was utilized at 90% power in pulsed mode for 5 minutes on each side. The lipoaspirate totals from each side were 500 cc. To assist flattening and resolution of the curtaining, Renuvion® was utilized at 60% power 4 lpm, 6 passes to the waist, 6 passes to the waist and hip and 6 passes to the bra roll on each side, 15 cm radially from each port. The techniques detailed in the previous patients were applied here.

These cases illustrate therapeutic and beneficial soft tissue contraction in patients that either were not a candidate for excision or who were but did not accept the concomitant scars of tissue excision. The use of Renuvion® effectively extended liposuction as an option to a non-traditional patient group of large weight loss patients that demonstrate damaged FSN. As all patients were satisfied and there have been no reoperations, the question of whether there is potential for further improvement or longevity with a subsequent Renuvion® treatment remains unanswered.

#### **Figure 3.**

*(a) Patient presented with little inner arm subcutaneous fat, laxity and grade 3 inner arm ptosis, and (b) pleasing contours are seen 3 months following VASER® and Renuvion® assisted liposuction.*

*Contractile Effects of Radiofrequency Energized Helium Plasma on the Fibrous Septal Network DOI: http://dx.doi.org/10.5772/intechopen.97849*

#### **Figure 4.**

*(a) Patient presented with excess back, waist and hip subcutaneous fat, laxity and curtaining of tissue, and (b) pleasing contours are seen 3 months following VASER® and Renuvion® assisted liposuction.*
