19 FaceTite: Procedure Technique

P. Paolo Rovatti

Abstract

Tissue tightening is one of the most common demands in aesthetic surgery worldwide and the primary purpose of an energy device is to provide an improvement of skin quality.

Skin laxity, with or without fat, of the lower third of the face is one of the main signs of an aging face.

Skin tightening procedures are among the most interesting innovations in the growing market of energy devices for a youthful face. We’ve reviewed our experience in the last six years with a bipolar radiofrequency (RF) energy device called FaceTite, which gave us a satisfactory result in terms of noexcisional procedure and long-lasting effectiveness.

Goals of this surgery are: local anesthesia technique, reduced procedure time, minimal downtime, great patient acceptance, and satisfying long-lasting results.

Many safety controls were introduced in order to improve the reliability of this device, and thanks to recent refinements the learning curve for this instrument has been shortened significantly. Combining synchronously this technique with fractional bipolar RF (Morpheus8) to improve “in and out” thermal stimulation in dermis, we can produce a marvelous change of the skin.

In conclusion, we can assert that this technology has shown diverse advantages, also thanks to the recent improvements in safety control and can thus be a powerful tool for surgeons and a reliable choice for patients.

Radiofrequency – skin tightening – FaceTite – noninvasive lifting – jawline ptosis – neck laxity

19 FaceTite: Procedure Technique

Radiofrequency is a relatively young technique that allows energy to be applied to the tissues in a bipolar manner, inside as coagulative energy and externally as cutaneous heating. This dual approach makes it possible to obtain a contraction of the fibrous septa and at the same time a cutaneous retraction. ¹

RF has been widely used in association with traditional liposuction, thanks to its tissue contraction action, which allows to carry out the procedure even in the presence of tissue laxity. This feature led in recent years to the recognition of RF as the method to prefer in cases of laxity of the region of the mandibular edge and neck, with or without adipose excess tissue.

Both male and female patients may be treated with cutaneous laxity of the mandibular border, the submental region, and the neck with or without fat accumulation. The preoperative evaluation is performed according to the Merz scales for neck and mandibular line and patients with a neck grade from 1 to 4 and a jawline grade from 1 to are considered suitable for treatment. The treatment of patient with higher degrees of tissue failure unfortunately results in partial and often unsatisfactory results and therefore they are considered a contra-indication related to the procedure.

It should also be considered that the presence of significant skin failure and a loss of adipose volume (1–2 grade Carruthers scale) with a high degree of photo and chronoaging (III–IV type in Glogau scale), represents a further contraindication to the treatment.

FaceTite is the device that belongs to the Body Tite equipment (Invasix Ltd, Israel), which is used for the treatment of the face and neck. This handpiece transmits a thermal effect to the adipose tissue determining a coagulation. The heat then radiates progressively towards the skin, crossing the derma to full-thickness, thus promoting the skin tightening effect (▶Fig. 19.1). The procedure is usually performed with subcutaneous infiltrative anesthesia (wet technique) using 20 mL of lidocaine 200 mg/10 mL + 60 cc of saline solution + 0.5 mL of epinephrine 1:1000. ²

**Fig. 19.1** (a) Area to be treated carefully. (b) Safe area below internal electrode.

The surgical treatment consists of introducing the internal probe of the handpiece through a small hole made with a 16 G needle, which must maintain a depth level between 5 and 8 mm (▶Fig. 19.2). The correct alignment of the two internal and external electrodes grants uniform heating of the tissue in its entire thickness. Radiofrequency energy is transmitted better through the vertical fibrous septa network (FSN) that is a path of least resistance and is parallel to the RF delivered. ³ RF ⁴ energy is transmitted preferentially in vertical FSN vs. horizontal layers which are perpendicular to the RF ⁵ ^, ⁶ and this leads to more tightening effects on the fat tissue. ⁷ The range of the internal temperature must remain between 65 and 70°C and allows the coagulation and contraction of the septa within the adipose tissue in a three-dimensional manner; on the cutaneous level the cut-off must remain within 38 and 40°C with consequent lower heat density, but with an effective skin tightening effect.

The handpiece is equipped with two sensors (internal and external) that control the subcutaneous and skin temperature until the energy supply is interrupted when the set parameters are reached. The delivery of the RF is automatically stopped also when the distance between the two electrodes increases or decreases too much: for example, if the internal probe is too superficial or when treating areas with curvatures. The device is also equipped with an impedance control system, which permits radiofrequency to be delivered only when the external handpiece is in full contact with the skin. As the subdermal temperature increases, the impedance is reduced, but if this happens too quickly, FaceTite stops automatically, thereby preventing skin burns. ⁸ This automatic control system allows treatment of surface fat without excessive risk of thermal damage. Radiofrequency delivers energy only between the cannula and the external electrode, preventing energy from being distributed below the cannula itself, then into the subfascial districts, hence avoiding harmful effects on vessel and nerves.

The handpiece is introduced through three holes: one in the submental region and two submandibular ones in the inferior-lateral margin of the DAO (LMF entry). These latter access points are used to treat the area above the mandibular edge by directing the handpiece towards the ear and then the area below the mandibular edge, in the lateral-cervical region.

From the submental access we proceed then to carry out the treatment of the interplatismatic region, moving the handpiece in caudo-cranial direction with fan-like technique.

Radiofrequency must be delivered with a retrograde movement in the district to be treated. In the area of the mandibular edge the treatment must be performed above and below the edge. The first passage is carried out slowly, stopping for about 1 second, and no more, every 1–2 cm to determine the decrease in tissue thickness, thanks to the vertical contraction of the connective septa. During this phase it will be easy to hear a crackle (popping sound) which is a sign of the coagulative necrosis of the superficial fatty tissue, immediately subdermal. The next passage, on the other hand, occurs with a slow but continuous movement in the previously tunneled tissue until the cut-off is reached.

The neck is conventionally divided into 3 parts: the interplatismatic region is reached through the submental access, while the two lateral areas through the submandibular accesses (▶Fig. 19.3). The treatment of the neck requires the use of the FaceTite handpiece with continuous retrograde technique until the cutoff is reached. The energy delivered in the region of the mandibular edge is 1.5–2.5 kJ per side, while in the neck is about 3–6 kJ of total energy.

**Fig. 19.3** (a) Treatment lines from entry point. (b) Neck treatment.

Liposuction before radiofrequency is never performed; if the fat excess in the submental region is particularly evident (fat plication greater than 1.5 cm), at the end of the procedure an aspiration of the liquefied fat with microcannula can be carried out, not more than 2 cc.

Patient selection should include moderate to medium-high ptosis of both the jawline and neck. Recent great weight loss may cause unsatisfactory results and therefore it is really important to wait for the patient to return in acceptable metabolic balance.

Absolute contraindications are patients with pacemaker, silicone or permanent fillers in the areas to be treated, while no contraindications should be considered with previous treatments in the involved areas (threadlift, previous facelift, fillers HA and CaHA). We found relative contraindications treating previous laserlipo procedures.

To maximize the results, this procedure can be combined with the transdermal fractional radiofrequency (Morpheus8) which, in the same session, can further improve skin tightening.

Using the local anesthesia previously done, the transdermal device with 24 needles is applied on the skin overlapping 30/40% on all neck areas reaching a result after two/three treatment (each apart 45 days) with a GAIS improvement scale of 74% by the patient (▶Fig. 19.4). ⁵ ^, ⁶ ^, ⁷ ^, ⁹ ^, ¹⁰ ^, ¹¹ ^, ¹² ^, ¹³ ^, ¹⁴ ^, ¹⁵ ^, ¹⁶

**Fig. 19.4** Fractional transdermal heating.

The procedure now is safer thanks to the new device cut-off control. The internal sensor cut-off precludes the fat from liquefying and creating possible necrosis thus reducing the possible related complications. No permanent thermal-related injuries were observed among our patients. Only a few neuropraxias of the mental nerve (four cases) were pointed out, each one pharmacologically resolved after few months.

Skin burns due to excessively superficial treatment resolved spontaneously without scarring. Persistent swelling (more than two months) was found in only few cases and was successfully resolved with manual lymphatic drainage. In conclusion, we can affirm that in this procedure, the relationship between minimal side effects and good results seems to be favorable.