Abstract
Radiofrequency (RF) technology has been used in different medical specialties for nearly 100 years (i.e., surgical electrocautery, cardiac ablation, joint tightening). However, aesthetic applications of RF first began in the early 2000s with monopolar modalities (i.e., Thermage). One historic challenge with RF has been the balance between efficacy and safety. Precedent devices lacked temperature control, which led to inconsistent results and potential thermal complications. This chapter discusses use of the latest bipolar RF modalities, which allow for volumetric heating of soft tissues with continuous temperature monitoring. This technology has been shown to successfully treat the “treatment gap” patients, demonstrating approximately 30% soft tissue tightening in properly selected patients.
92 Body Radiofrequency Fat Removal/Skin Tightening
Key Points
Significant advancements in minimally invasive body contouring have been made over the past 10 years.
Increasingly, patients are seeking minimally invasive methods to tighten skin and remodel adipose tissue. A large treatment gap exists among three types of patients: (1) the younger demographic, who desire soft tissue tightening without traditional operations, scars, and downtime; (2) patients with soft tissue laxity who are not “severe enough” to justify an excisional procedure, but not “mild enough” to rely on liposuction with soft tissue contraction alone; and (3) those with recurrent laxity who have already underwent traditional excisional procedure. In these populations, plastic surgeons risk under- or overtreating with traditional methods.
Through impedance of electromagnetic current, radiofrequency (RF) waves lead to differential heating across distinct tissue types consistent with Ohm’s law (energy = current × impedance × time). For example, adipose tissue is less conductive than water (higher impedance), and leads to generation of higher temperatures than muscle. Once soft tissue temperatures reach 50 °C and skin surface reaches 40 to 42 °C there is a trigger to induce neocollagenesis, angiogenesis, and elastogenesis. Through different applications of RF energy (i.e., monopolar, bipolar, multipolar, microneedling), subdermal adipose remodeling (SAR) and long-term soft tissue contraction can be safely and consistently achieved.
The procedure may be performed safely and effectively under local anesthesia with an excellent safety profile and return to daily activities within 24 to 36 hours.
92.1 Preoperative Steps
92.1.1 Analysis
A thorough history and physical examination with a focus on previous procedures, significant weight changes, pregnancy status, and a preoperative analysis to identify areas of subcutaneous excess, dermal striae, and tissue laxity.
Areas of volume excess and areas of significant laxity are marked preoperatively with the patient in the standing position with the target areas in the dependent position to facilitate intraoperative accuracy.
For upper extremities, the forearm is flexed at 90 degrees and the humerus parallel to the floor to demonstrate areas of maximal laxity in the upper posterior arm.
Preoperative photography is essential for postprocedural analysis.
When indicated, laboratory values including complete blood count (CBC), chemistry profile, coagulation tests, and urine pregnancy tests in women of child-bearing age are obtained.
The patient is given oral medications including an antibiotic, sedative, and pain reliever 30 to 45 minutes preoperatively.
92.2 Operative Steps
See Video 92.1.
92.2.1 Tumescent Infiltration
Following standard prep and drape, the previously identified access points are injected with 1% lidocaine with epinephrine.
Access incision is made with either 14-gauge needle or #11 blade scalpel.
Standard infiltration cannula is used to deliver the tumescent fluid (Table 92.1) into the deep subcutaneous space at a low speed.
Table 92.1 Modified tumescent fluid (0.1% lidocaine concentration)
Modified tumescent fluid (0.1% lidocaine concentration)
1,000 mL normal saline
1000 mg lidocaine (50 mL of 2% plain lidocaine)
10 mL sodium bicarbonate
1.5 mL 1:1,000 concentration epinephrine
Once the deep and intermediate subcutaneous fat spaces are adequately infiltrated, the cannula is placed into the superficial fat space in order to obtain complete analgesia of all layers with the most densely innervated subdermal space injected last.
It is important to tumesce at least 1 to 2 cm beyond the marked areas to achieve full analgesia in the treatment zone.
In the awake patient, slow infiltration speed will achieve a comfortable state for the patient because the rate of distension correlates with discomfort.
Infiltrate “low and slow”: Begin with the tumescent injected into the less richly innervated deep subcutaneous fat space at low speed.
Only progress to the next step once complete analgesia is achieved.
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