**3. Patient considerations**

Recognizing that there are several different applications and techniques in the approach to the head and neck with Renuvion™, it is important to discuss the

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

patient variables to consider who will achieve the best outcomes with which technique and not to mention considering the variabilities of the settings.

Using the device to tighten the subdermal neck only with or without liposuction, the ideal patient candidate is the younger patient, with minimal laxity, absence of redundant skin and inherently responsive skin elasticity. For the patient with inherent deep structure concerns such as platysmal banding, submandibular gland ptosis, and more significant skin laxity, but mild skin redundancy, a minimally invasive subdermal approach with Renuvion™ can be considered in conjunction with other minimally invasive techniques such as suture suspension platysmaplasty or with MyEllevate™. In the patient with significant facial aging, skin laxity with excess skin redundancy, the authors' experience is that an open traditional facelift approach combined with subdermal Renuvion™ yields best results. For the Fitzpatrick patient I-III with significant rhytidosis, solar elastosis, ablative resurfacing—both fractional and full resurfacing using Renuvion yields impressive results unsurpassed by other technologies currently on the market.

The Renuvion handpiece affords the physician to use one handpiece for the subdermal and resurfacing approaches. Other technologies cannot be used this way which makes the renuvion technology more attractive. With CO2 laser and erbium Yag laser, wrinkle reduction is noted and has been studied in depth [8]. The authors have found that not only is wrinkle reduction improved, but the skin contraction with lifting of the lateral brow, medial brow and upper lip is seen much more with Renuvion. A split face study would need to be performed to truly delineate the superiority of renuvion for improving sagging skin. The authors decided to resurface with renuvion when the patient's skin is more loose an could benefit from lifting otherwise CO2 is their other method of choice for wrinkle reduction and improvement of skin texture with less downtime. Also hypo pigmentation is seen 19% of patients getting fully ablative CO2 laser [9]. While the authors noted some hypo pigmentation, it was not as high as 19%.

## **4. Technique**

The Renuvion™ handpiece is very user dependent and technique cannot be discussed enough. It is different than most currently used laser devices that have a precise pulse width, spot size, duration with an exact depth of penetration. The Renuvion™ energy delivery is akin to using a laser in continuous mode. For this reason technique will directly impact time on tissue, energy delivered and depth of penetration. When used in pulsed mode the Renuvion™ helps regulate the depth and time on the skin for the first time users, but does not give the same degree of contraction or wrinkle reduction as seen in the non-pulsed mode. The most important determination of usage is to know that too much time on the subdermis or epidermis will cause increased depth of injury and result in permanent scarring. Furthermore, placing the handpiece too superficially in the subdermis will cause undulating acne like scars. It is recommend that a physician train users prior to the use on patients.

#### **4.1 Subdermal neck only**

When Renuvion™ is used in a minimally invasive manner as a stand-alone device for the subdermal neck, the ideal patient candidate is the younger patient in whom there is mild skin laxity in the absence of excessive skin redundancy. The subcutaneous neck is liberally infiltrated in a tumescent technique, this can be extended to varying degrees above the mandibular border to improve and impact

#### **Figure 5.**

*This patient had Renuvion™ resurfacing performed with improvement of wrinkles and skin texture. The tightening of the lower lid skin has improved her fat pseudoherniation and her forehead contracted 1 cm.*

energy along the jawline. Subdermal tunneling is then performed through stab incisions as seen in **Figure 6** create channels to pass the Renuvion handpiece without complete disruption of the underlying subdermal fibroseptal network. This can be performed using a liposuction cannula or other blunt tunneling instrument ideally measuring up to 3.5–4 mm in width. At this point, depending on the patient, the surgeon may elect to perform submental lipectomy or neck liposuction. It is important to point out that there needs to be open communication in your tunneling between the access points to facilitate Helium gas egress when the Renuvion™ handpiece is used. It is the authors' experience that taking the time to create sufficient tunneling broadly and widely involving the entire anterolateral neck yields best results. The handpiece is then passed subdermally 5 mm from the subdermis using the created subdermal tunnels. Energy is typically deployed in a retrograde fashion as the handpiece is removed and it is important to understand the handpiece should be in continuous motion when the energy is applied. The speed of the handpiece should be at approximately 1 cm/second maintaining a distance roughly 5 mm from the dermis to reduce risk of scarring. Energy delivered typically depends on the inherent thickness of the skin. In the thin-skinned patient energy of 60% up to 80% in the thicker-skinned patient can be considered at flow rates of 1.5–2 L. Typically, the neck and jawline are divided into subunits including the jawline, midline neck/submental area, the lateral neck, and posterior to the SCM. Four to six passes are performed 1 cm apart in each area, at a subdermal depth where the light from the wand can still be seen, but the skin is not tented under tension. As the energy is being delivered above the mandibular border, in the minimal incision technique, it is important to place firm hand pressure at the mid-cheek to prevent helium gas from extravasating into the cheek and orbit.

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

#### **Figure 6.**

*Typically, 3 small entry point incisions (measuring 1 cm or less) are made—One is made under each earlobe at the facial junction as well as a small submental entry point incision.*

Approximately a total of 4–6 KJ of energy is delivered to the neck and jawline in this technique. The exact energy delivered has not been studied to see what achieves optimal results.

### **4.2 Subdermal neck with platysmaplasty**

In the patient for whom there is mild–moderate skin laxity in the presence of platysmal banding and or submandibular gland ptosis, addressing the underlying muscle in conjunction with subdermal Renuvion™ yields a better result than treatment of the subdermal neck alone. In this situation, the small entry point earlobe incisions remain the same, but the submental incision may be extended if an open platysmaplasty is to be performed. A novel limited incision technique is the combined use of platysmal band division and submental neck suture suspension using the LED light-guided device known as myEllevate™. In this case, the platysmal bands are percutaneously divided using the ICLED suture. The entry point incisions as described above remain the same. The neck is liberally infiltrated with tumescent solution. Subdermal tunnels are created in the midline and antero-lateral neck. At this point, the surgeon may proceed with submental and or neck liposuction if indicated. The Renuvion™ is then used at this stage, passing the wand through the created subdermal tunnels, delivering energy on withdrawal of the handpiece. Four to six passes are performed 1 cm apart as described above. Once more approximately 5–6 kJ of energy is delivered to the neck and jawline. Following completion of the Renuvion treatment of the fibroseptal network and subdermal neck, the MyEllevate™ suture is used to create a trampoline suture suspension from mastoid tip to mastoid tip to support the submental neck. The energy will not damage the previously placed sutures if the Renuvion™ needs to be passed again.
