3.1 The basic principles of RFAL treatment are


BodyTite®: The Science and Art of Radiofrequency Assisted Lipocoagulation (RFAL)… DOI: http://dx.doi.org/10.5772/intechopen.83446

#### Figure 6.

The various BodyTite® applicators are bipolar RF electrodes, with the internal, positively charged electrode being inserted into the adipose tissue and the external, negatively charged electrode sliding along the surface of the skin in tandem with the internal. RF flows from the internal, uncoated electrode with the RF energy is ablative close to the electrode, up through the adipose to the dermis, skin and large diameter electrode where the RF is then more diffuse and non-ablative in nature. The physician can control the distance between the electrodes by setting the inter-electrode distance on the proximal end of the hand piece. Each setting, 1–6 on the dial corresponds approximately to the number of centimeters between the electrodes.


Other physicians will withdraw very, very slowly, allowing the temperate to rise to therapeutic cut off while withdrawing. GOAL of this step is to ensure as much of

#### Figure 7.

The stamping technique. Stay in each spot until the internal thermal cut-off of 69–70 is reached, then move to the next spot.

#### Figure 8.

Vertical sequential thermal stimulation to 69–70° cut-off is achieved, which is the temperature that optimizes the FSN contraction and remodeling, resulting in the 35% or greater skin and soft tissue contraction.

the FSN experiences 69°C for optimal contraction. This process is performed at each vertical levels determined by the "skin pinch" and 2 cm formula. Multiple, sequential vertical FSN thermal stimulation and contraction is then achieved, optimizing the 3D soft tissue skin and adipose contraction and body contouring results (Figure 8).

9. Avoiding a peri-port burn: when you get close to the port, ensure you do not end up at the same spot each time to avoid a peri-port burn. Try to zigzag through the adipose tissue as you advance and withdraw always to a different spot around the port (Figure 9).

Once I have stamped retrograde on the way back, or using a slow moving technique, I will keep my foot on the pedal and perform several back and forth BodyTite®: The Science and Art of Radiofrequency Assisted Lipocoagulation (RFAL)… DOI: http://dx.doi.org/10.5772/intechopen.83446

#### Figure 9.

Zig zag the applicator through the adipose tissue to avoid coming the same peri-port location each time, which will help avoid a peri-port thermal injury.

passes, slow moving technique, at that depth to ensure optimal thermal coverage of the FSN, as well as more complete lipocoagulation and liquification (easier aspiration, perhaps less trauma to the FSN, edema and pain) and coagulation of small venules and arterioles prior to aspiration (less ecchymosis). Again, it is important to zigzag your back stroke to avoid a peri-port burn (Figure 9).


already been performed. It is more efficient to switch to dedicated aspirating cannulas or PAL systems when the thermal coagulation is done, than continue to aspirate with the RFAL cannula. United States BodyTite® users, have a non-aspirating cannula (FDA requirement) and suction begins once the vertical sequential thermal stimulation has been completed, again using dedicated aspiration cannula's or PAL systems.

13. RFAL first or last? From a purest perspective, there are advantages to performing BodyTite® RFAL first, followed by completion aspiration. However, some physician, particularly with larger BMI patients or large zones, perform the aspiration first, followed by BodyTite® thermal coagulation of the reduced, near final contour second (less tissue to heat) and perhaps refinement aspiration last. Although this approach is much faster, some of the theoretical disadvantages are: (i) more trauma to the FSN before thermal coagulation and potentially less contraction. (ii) traumatic aspiration disruption of small vessels may result in more ecchymosis, edema pain, hemosiderosis and hyperpigmentation.

## 3.2 Patient selection

Like any liposuction or Body Shaping procedure, RFAL patients need have realistic expectations, no uncontrolled medical conditions and appropriate skin tone and focal or multifocal lipodystrophy concerns. The BodyTite® family of applicators allow physicians to selection the right-hand piece for the job. International Physicians have a slightly different array of hand pieces and thermal controls than American physicians (FDA requirements) but both parameters are outlined below. In general, BodyTite® RFAL treatment can deliver up 35% area contraction over 12 months and, as such, does allow the physician to extend the indications for liposuction to patients with more skin laxity than they might have in the past. Those older patients, or those with larger BMI's, weight loss and weight gain, multiple parity may be BodyTite® candidates. The optimal RFAL soft tissue contraction means that physicians may be able to offer more minimal excisions: mini tummy tucks, axillary arm-lift, anterior inner thigh lifts and mini facelift in combination with BodyTite® RFAL treatment.

### 3.3 Port selection

Once you have selected a good BodyTite® candidate, then the appropriate port is selected to access the targeted lipocoagulation areas. Both RFAL BodyTite® and final aspiration contouring will be performed through the same port. Generally, this author prefers a single, well concealed port. The authors most favored zonal access ports are outlined in Figure 10.

### 3.4 RFAL thermal approach

Vertical sequential multi-level thermal coagulation, both stamping and/or slow moving to the deep (USA) and skin (International and USA) end points. Aspiration generally follows the heating (Figure 8).

#### 3.5 Parameters

USA BodyTite® physicians: cut off of 69–70°C internal and 38–40°C external and 120 second treatment cycles. In the USA, the energy in watts is not entered as the

BodyTite®: The Science and Art of Radiofrequency Assisted Lipocoagulation (RFAL)… DOI: http://dx.doi.org/10.5772/intechopen.83446

Figure 10. Some of the standard BodyTite RFAL and aspiration ports.

device will deliver the precise amount of energy to heat the adipose at 20°C/cm<sup>3</sup> /s, while, for International BodyTite® users, the energy in watts will need to be entered and this will depend upon the hand piece selected and thickness of the flap. General energy settings for the international physicians are 50–60 W for the 3.7 mm ˜ 25 cm and <sup>17</sup> cm large hand pieces, and <sup>40</sup>–<sup>50</sup> <sup>W</sup> for the 2.4 mm ˜ <sup>17</sup> cm NeckTite® hand piece. For the FaceTite® 1.2 mm ˜ <sup>10</sup> cm hand piece, <sup>25</sup> <sup>W</sup> is used. The New AccuTite® 0.9 mm ˜ <sup>8</sup> cm applicator only requires <sup>10</sup>–<sup>20</sup> W.

## 3.6 Thermal end points

The thermal endpoints are thermal, 69–70° internal (USA) and 38–40° external cut off (USA and International). The final contour endpoints remain the art of the physician and are the aspiration endpoints.

#### 3.7 Postoperative care

Postoperative BodyTite® care is similar to non-thermal liposuction and the author favors 6 weeks of compression garmenting. The first week is with silicone coated foam compression and the next 5 weeks the garment alone. For Abdominal RFAL BodyTite® cases, a small #7 JP drain is used, as seromas are much more common than with SAL, with an incidence approaching 8–10%. Presumably post RFAL seroma are more common resulting from temporary thermal damage of the lymphatics that takes some time to normalize. The drain is removed when there are three consecutive days with less than 20 cc of drainage each day. The first 3 weeks of garmenting are 22 h per day, which is reduced to 12 h a day (day or night time) for the next 3 weeks. Full ambulation is encouraged immediately, but return to low impact activities, such as an elliptical, stair climber, exercise bike at the end of 3 weeks and high impact exercise, running, spinning, etc. at the end of 6 weeks.

Noninvasive bulk heating devices, to achieve even better skin tightening can be deployed when the skin is less sensitive at 8–12 weeks. Shock wave devices can be used on any areas of lumps and areas of firmness.

BodyTite® leaves the skin very stiff, indurated and firmer for longer than nonthermal SAL/PAL or UAL and there is strong sense of tightness and contraction on the part of the patient for the first 6–9 months, which is the contraction process. At 3–6 months, for any areas of slight contour excess, noninvasive, localized fat destruction technologies, like SculpSure®, BodyFx®, EMSculpt®, CoolSculpting® and Ultrashape®, can be used to try to improve the contour non-surgically.
