Advances in Cosmetic Surgery 3 (2020) 173–188

ADVANCES IN COSMETIC SURGERY

Advances in Skin Tightening

with Liposculpture
Plasma Technology Versus Radiofrequency
Ryan Neinstein, MD, FRCSCa,*, Christopher D. Funderburk, MD, MSb
a
Lenox Hill Hospital, Northwell Health System, 135 East 74th Street, New York, NY 10021, USA; bDepartment of Plastic Surgery, Manhattan
Eye, Ear, and Throat Hospital, Northwell Health System, 210 East 64th Street, New York, NY 10065, USA

KEYWORDS
 Liposculpture  Liposuction  Skin tightening  Radiofrequency  Plasma  BodyTite  Renuvion

KEY POINTS
 The term, liposculpture, is used to describe a procedure that includes both fat reduction and skin tightening.
 Skin tightening involves both skin retraction at surgery and skin tightening with neocollagenesis in the long term.
 The Renuvion/J-Plasma system produces skin retraction and tightening by 2 mechanisms, radiofrequency and ionized
helium (plasma).
 The BodyTite system uses radiofrequency energy for soft tissue tightening by immediate and long-term thermal
contraction of the fibroseptal network in the subcutaneous space and nonablative, inflammatory heating of the dermis.

Video content accompanies this article at http://www.advancesincosmeticsurgery.com.

Since the latter half of the twentieth century, there has
been an increasing focus on the body as a vehicle for
identity and self-expression, with a greater recognition
of the role of appearance and the desire for
self-improvement [1]. In 1983, Illouz presented his
technique of liposuction at the annual meeting of the
American Society of Plastic Surgeons [2]. In 2014, lipo-
suction replaced breast augmentation as the most
frequently performed surgical procedure, with a 16%
increase over 2013 cases and more than $1 billion spent
on the procedure in the United States alone [3].
Specific depths of subcutaneous fat, which vary in
different body locations, should be suctioned. For
example, the deep and/or intermediate fat layer should
be primarily suctioned, but, in rare cases, superficial or
subdermal liposuction may be appropriate [4,5].
Surgeons noticed that as the subdermis is approached
with liposuction, the potential for skin retraction
increased, especially in areas with thin skin [6].
The final frontier in liposuction is skin tightening.
Skin tightening involves both skin retraction at surgery
and skin tightening with neocollagenesis in the long
term. The term, liposculpture, is used to describe a pro-
cedure that does both fat reduction and skin tightening.
Various lasers and lights have been used in the past
for the improvement of skin quality and texture. They
act by stimulating new collagen formation, leading to
skin retraction in the body and face. All these devices
are applied externally, and the energy (laser, light, or
high-frequency ultrasound) must cross the epidermal
and dermal barriers to reach their targets in the connec-
tive tissue [7].

*Corresponding author, E-mail address: Drneinstein@neinsteinplasticsurgery.com

https://doi.org/10.1016/j.yacs.2020.01.012 www.advancesincosmeticsurgery.com
2542-4327/20/ © 2020 Elsevier Inc. All rights reserved. 173
174 Neinstein & Funderburk
Energy has been applied in some form to the under-
side of tissue since the beginning of recorded history.
Continuous improvement of methods for utilizing the
beneficial effects of heat on tissue eventually led to
the development of the basic concepts of electrosurgery
known today. In October of 1926, Dr Harvey Cushing
used an electrosurgical unit developed by Dr William
T. Bovie to successfully remove a highly vascularized
brain tumor from a patient after previous failed
attempts. Today, electrosurgical instruments are used
in almost every surgical procedure performed world-
wide [8].
Through this long history, the heat effects of the
radiofrequency (RF) alternating current used in electro-
surgery on cells and tissue have been well established.
Normal body temperature is 37 C and, with normal
illness, can increase to 40 C without permanent impact
or damage to the cells of the body. When the tempera-
ture of cells in tissue reaches 50 C, however, cell death
occurs in approximately 6 minutes. When the tempera-
ture of cells in tissue reaches 60 C, cell death occurs
instantaneously. Between the temperatures of 60 C
and just below 100 C, 2 simultaneous processes occur.
The first is protein denaturation, leading to coagulation
and subsequent reorganization of collagen which, when
controlled, can lead to the effect of tissue tightening.
The second is desiccation or dehydration as the cells
lose water through the thermally damaged cellular
wall. As temperatures rise above 100 C, intracellular
water turns to steam, and tissue cells begin to vaporize
as a result of the massive intracellular expansion that oc-
curs. Finally, at temperatures of 200 C or more, organic
molecules are broken down into a process called
carbonization. This leaves behind carbon molecules
that give a black and/or brown appearance to the tissue
[9,10].
This article focuses on 2 types of technology that are
changing the way body contouring is performed. Inno-
vative use of ionized helium led to the development of
the first device. The Apyx Medical Corporation Renu-
vion (Clearwater, Florida) (formerly branded as J-
Plasma) helium-based plasma technology has Food
and Drug Administration (FDA) clearance for the cut-
ting, coagulation, and ablation of soft tissue. The
Renuvion system consists of an electrosurgical gener-
ator unit, a handpiece, and a supply of helium gas.
RF energy is delivered to the handpiece by the gener-
ator and used to energize an electrode. When helium
gas is passed over the energized electrode, a helium
plasma is generated that allows heat to be applied to
tissue in 2 different and distinct ways. First, heat is
generated by the actual production of the plasma
beam itself through the ionization and rapid neutrali-
zation of the helium atoms. Second, because plasmas
are good electrical conductors, a portion of the RF en-
ergy used to energize the electrode and generate the
plasma passes from the electrode, through the plasma,
and to the patient, where it heats tissue by passing cur-
rent through the resistance of the tissue, a process
known as Joule heating. Thus, this system produces
skin retraction and tightening by 2 mechanisms both
RF and ionized helium.
A second system that is reviewed is BodyTite from
InMode Aesthetic Solutions (Yokneam Illit, Israel),
which uses standard bipolar energy. It has been postu-
lated that RF energy–modulated soft tissue tightening
is because of immediate and long-term thermal contrac-
tion of the fibroseptal network (FSN) in the subcutane-
ous space and because of a nonablative, inflammatory
heating of the dermis caused by the RF energy applied
in a bipolar manner. Recent randomized, blinded
studies have shown 35% soft tissue contraction at
12 months with RF-assisted lipocoagulation (RFAL).
This contraction via RFAL was compared with 8.1%
soft tissue contraction observed in nonthermal, tradi-
tional suction-assisted lipoplasty (SAL) at the same
time interval [11,12].
PREOPERATIVE ASSESSMENT
It is important for physicians, early in a consultation, to
assess patients’ motivations for surgery as well as the de-
gree of concern they have about their current physical
state in order to meet their expectations. Patients with
body dysmorphic disorder will not benefit from surgi-
cal intervention and have been observed in aesthetic
surgery settings to seek surgical enhancement at a re-
ported prevalence of 6% to 15% [13].
MEDICAL HISTORY
Many patients take vitamins, minerals, and supple-
ments and do not report them to their practitioner
because they feel they are inconsequential. Taking a
directed history and stopping all nonessential agents
before surgery can reduce the risk of a bleeding-related
complication [14].
The percentage of the US population using at least 1
psychotropic medication increased from 5.9% in 1996
to 8.1% in 2001 [15]. First-line antidepressants
include selective serotonin reuptake inhibitors. These
medications along with others can compete with lido-
caine for metabolism in the liver increasing the risk of
toxicity [16]. Smoking is an independent risk factor for
 Advances in Skin Tightening with Liposculpture
wound healing complications. The ameliorating ef-
fects of cessation are supported by level 1 evidence,
which suggests that the optimal duration of preopera-
tive cessation of any form of nicotine is 4 weeks or
longer [17]. Diabetes mellitus is an increasingly com-
mon medical condition, affecting approximately 8%
of the population of the United States [18]. Infections
account for 66% of postoperative complications and
approximately one-quarter of perioperative deaths in
patients with diabetes mellitus. Fortunately, tight gly-
cemic control has been shown to have a profound ef-
fect on reducing the incidence of many of these
complications in a variety of surgical populations
[19]. Complication rates in orthopedic surgery have
been shown to be lower in patients whose hemoglobin
A1C` is less than 6.5% [20].
Venous thromboembolism (VTE) is a serious
complication with risks for short-term mortality and
long-term morbidity. VTE has been shown to be the
single largest cause of mortality in patients undergoing
high-volume liposuction [21]. Using regional or
tumescent anesthesia alone has been shown to have
statistically significant lower incidences of postopera-
tive deep vein thrombosis [22]. If patients are on b-
blockers for hypertension, it should be confirmed
they are cardioselective to prevent a hypertensive crisis
from an unopposed a-vasoconstriction [23]. Accord-
ing to the American College of Cardiology/American
Heart Association guidelines, functional status is a reli-
able predictor of perioperative and long-term cardiac
events [24].
PHYSICAL EXAMINATION
A carefully directed history and physical should look for
stigmata and sequelae of chronic disease. When exam-
ining the abdomen, the physician should pay particular
attention to surgical scars as potential sources of
hernias. Visceral perforations are most common in the
small intestine in patients with abdominal hernias
[20]. Umbilical hernias are relatively common findings,
particularly in postpartum patients seeking abdominal
contouring surgery. Classification and documentation
of the extent of diastasis recti and visceral fat compo-
nent are essential. If patients have a history of weight
loss surgery, the location of associated ports should be
identified. It is possible to perform liposuction above
a port; however, it may make the port more visible
and palpable. Skin quantity and quality should be
assessed and differences between excisional procedures
and liposuction should be discussed with the patients.
Of particular interest to many patients are stretch marks
175
and cellulite. Patients should understand that liposuc-
tion does not improve cellulite or stretch marks and
potentially makes the appearance worse.
INFORMED CONSENT AND PHOTOGRAPHY
Accurate photographic documentation has become
essential in reconstructive and cosmetic plastic surgery
both for clinical and scientific purposes [25]. Generally,
informed consent requires that a patient be informed of
the risks of treatment, prognosis, and alternative treat-
ments before consenting to treatment. Surgical consent
has evolved and is not an event or a signature on a form
but is an ongoing process of communication that
continues throughout preoperative, perioperative, and
postoperative care.
WETTING SOLUTIONS
The current options for wetting solutions are dry, wet,
superwet, and tumescent. The essential differences
between these techniques focus on the amount of infil-
trating solution injected into the tissues and the resul-
tant blood loss as a percentage of aspirated fluid. The
dry technique involves no infused fluid and results
in approximately 25% to 40% blood loss of the vol-
ume removed. Blood loss has been estimated to repre-
sent approximately 1% of the liposuction aspirate
volume for both tumescent and superwet techniques
[26]. Swanson[27] felt that this was a gross underesti-
mation and has shown that there is substantial extra-
vascular third-space blood loss into the interstitial
tissues correlating to an approximate 2-point percent-
age decrease in hemoglobin for every 2500 mL of aspi-
rate [28]. True tumescent anesthesia is considered a 3:1
infiltrate to aspirate under pure local anesthesia. Most
plastic surgeons report using a wetting solution that is
a variation of superwet anesthesia. Tissue blanching
and moderate tension are considered clinical end-
points of infiltrate [29]. Recent data suggest that, for
patients undergoing general anesthesia with the super-
wet technique, the lidocaine component may be
reduced and/or eliminated without an increase in
postoperative pain [30].
OPERATIVE CONSIDERATIONS
Cannulas
There is a multitude of cannula port and length options
available. Nonblunt cannulas typically are used for
breaking up scar or discontinuous undermining. In
general, blunt-tipped cannulas are used to minimize
176 Neinstein & Funderburk
perforation risk and smaller-diameter cannulas are used
to minimize contour irregularities. Aspiration has been
found to be directly proportional to cannula and
suction-tubing diameter and inversely proportional to
cannula and suction-tubing length [31]. Beck and col-
leagues [32], with a proprietary manufacturing process,
found multiport and dual-port cannulas significantly
more efficient at aspiration compared with the standard
Mercedes tip cannula.
Adjunctive Liposuction
Technology/Techniques
Power-Assisted Liposuction
Power-assisted liposuction (PAL) is a commonly used
technology that uses a variable-speed motor to provide
reciprocating motion to the cannula, which, in combi-
nation with the reciprocating action of a surgeon’s
arm, facilitates removal of adipose tissue. The principal
advantages of PAL are treatment speed, economy of mo-
tion, and reduced operator fatigue [33].
Markings
Areas to be suctioned typically are marked with a circle
in a topographic pattern. Zones of adherence and areas
to avoid are marked with hash marks [34]. Some inves-
tigators advocate grid markings to standardize resection
and reduce contour irregularities [35]. Incisions should
be placed in natural creases to minimize visibility and
some investigators recommend placing bilateral access
incisions asymmetrically to avoid scars that appear
planned. It is important to review all markings and ac-
cess incision locations with patients in front of a mirror
before they are medicated.
Tips/pearls
1. Patient is intubated in the supine position; then, the
abdomen is infiltrated along with flanks or any pro-
posed sites; the patient then is turned to the prone
position and injection continues.
2. Infiltration is performed off the field with sterile
gloves, local anesthetic, and povidone-iodine prep-
aration at the cannula insertion site.
3. A stab wound incision with a #15 blade is made for
the entry site.
4. The authors prefer supine and prone positions to
adequately address flanks, hips, and medial thighs
as opposed to supine-lateral decubitus procedures.
5. The patient should be hyperextended when liposuc-
tion on the abdominal wall is performed, to reduce
the risk of visceral perforation from the injection
needles or cannulas.
Intraoperative Details
1. Systemic anesthesia is administered by an anesthesi-
ologist in conjunction with the infiltration of super-
wet infiltrate, or the patient receives oral anesthesia
30 minutes before the procedure and has tumescent
fluid up to 35 mg/kg of lidocaine injected at a very
low rate. A suggested rate of 150 mL/min is well
tolerated in tumescent-only liposuction.
2. Intraoperative steroids are given. A first-generation
cephalosporin, or clindamycin if a true penicillin
allergy exists, is administered perioperatively.
3. Stab wounds (disposable #15 blade) for intro-
ducing wetting solutions are injected with 1% lido-
caine and epinephrine 1:1000.
4. Wetting solution is infiltrated into the deep subcu-
taneous tissue until tissue blanching and moderate
tension using superwet anesthesia (1 L Ringer’s
lactate solution, 20 mL 1% lidocaine, and 1 mL
1:1000 epinephrine for general anesthesia or custom
weight-based formulas for local liposuction cases).
5. Injection is done with a 14-gauge to 16-gauge multi-
port reusable blunt cannula at a rapid infusion rate
of 200 mL/min to 300 mL/min.
6. Prepping and draping are done at the same time as the
surgeon scrubs; this allows for diffusion of the wet-
ting solution and for the epinephrine to take effect.
7. After a surgical time-out, a variety of blunt Mercedes
cannulas in the 1.8-mm to 5-mm range are used with
PAL. The endpoint of suction includes visual inspec-
tion, palpation, and increase in blood in the aspirate.
Skin-Tightening Devices
1. The Renuvion device (see Video 1 for demonstration)
is used after liposuction is performed. The pistol grip
device is deployed in a retrograde manner. The system
provides a total of 40 W, and the energy can be
changed based on a percentage of the 40 W. For the
body, a setting of 90% is suggested, and 60% is recom-
mended for the neck. Once engaged, the device is
drawn backwards from the end of the treatment
area toward the entry site. No more than 5 strokes
are performed for every 2 cm. The device is disengaged
2 cm from the entry site to prevent incision burns. The
helium gas needs at least 2 stab incision sites to have
adequate space to escape. The authors typically expel
the gas manually between moving areas and uses a 3-
mm cannula to gently suction out the helium once
completed in order to reduce the risk of subcutaneous
emphysema. When controlling the flow rate in
 Advances in Skin Tightening with Liposculpture
general, the authors prefer lower flow rates in the
body to allow more heat to be concentrated and
higher flow rates in the neck where skin is thinner
and more susceptible to burns.
2. As opposed to the Renuvion device, which is used af-
ter liposuction, BodyTite is used before. After tumes-
cent infiltration, the inferior electrode of the
BodyTite device is placed into the subcutaneous
space with the corresponding external electrode on
the surface of the skin. Sterile aqueous-based gel is
used to decrease the impedance of the contact patch
between the skin and the external electrode. The
RFAL device settings include an epidermal tempera-
ture maximum setting (Tmax) of 38 C to 40 C and a
power setting at 38 W. The device is moved in a back-
and-forth motion similar to liposuction technique to
deliver RF energy evenly. Multiple depths of the soft
tissue are treated to the target temperature with spe-
cial consideration given to not exceeding the preset
Tmax. The device has a real-time thermostat that
gives continuous temperature reading at the skin sur-
face. The automatic cutoff feature prevents overheat-
ing the tissues as the current is discontinued as soon
as the high temperature setting is reached.
POSTOPERATIVE CARE
Traditionally, prolonged use of elastic compression gar-
ments was advocated. The general rule of thumb was for
patients to wear the garment for 1 week for every decade
of life (40-year-old patients would wear garments for
4 weeks). Prolonged compression can cause skin
creases, hyperpigmentation, pain, and swelling. Some
ways to minimize swelling and postoperative compres-
sion included minimally traumatic surgical technique,
not suturing the incisions (as recommended by Toledo
and Mauad [36]), and applying bulky absorbent dress-
ings for the first 24 hours to 48 hours to allow the excess
remnant fluid and serous reaction to flow out. Klein
[37] advocates for bimodal compression. During the
first stage of bimodal compression, a high degree of
compression is maintained for as long as drainage per-
sists. The second stage of bimodal compression begins
24 hours after all drainage has ceased and uses either
moderate compression or no compression.
COMPLICATIONS
Local
With appropriate patient selection and minimally trau-
matic techniques, many complications can be avoided.
Overly aggressive liposuction can lead to seromas. The
177
collection of serous fluid in a treated area may lead to
extensive breaking of the fibrous tissue network, leading
to a single cavity formation [38]. The lower abdomen in
patients with high body mass index is a common area
for seromas. Infection is extremely uncommon (less
than 1% incidence) [20]. This low infection rate may be
due to a combination of sterile technique, small incisions,
and the antibacterial effects of lidocaine. The most com-
mon postoperative complication is contour irregularities
with an incidence of 2.7% [39]. Illouz [40] recommends
that as a rule the contour should be slightly undercor-
rected to allow for postoperative fat lysis, which amplifies
the result. Using small cannulas, not performing superfi-
cial liposuction, turning the suction off when exiting inci-
sions, crisscrossing areas, constantly analyzing areas
(visual and tactile), and proper positioning all can help
reduce the chance of contour irregularities. Both devices
can cause burns and caution should be used when com-
bined with aggressive liposuction or the addition of other
energy-based modalities, such as ultrasound-assisted
liposuction. Relatively infrequent skin conditions, such
as hyperpigmentation, necrosis, and erythema ab igne,
can be seen. Underlying connective tissue disease and
smoking along with superficial aggressive liposuction
may contribute to these complications [41].
Systemic Complications
The most frequent potentially lethal complications associ-
ated with liposuction are pulmonary embolism, sepsis,
necrotizing fasciitis, and perforation of abdominal organs.
Grazer and de Jong [15], in a North American survey of
American Society for Aesthetic Plastic Surgery members,
found a fatality rate of 19.1 per 100,000 liposuction pro-
cedures. The major cause of death was pulmonary throm-
boembolism. Even though dermatologic studies of true
tumescent liposuction have reported the risk of death
from liposuction procedures to be zero in a series
66,000 cases, there are reports of deaths in awake tumes-
cent liposuction [20,42]. Major risk factors for the devel-
opment of severe complications are poor standards of
sterility, the infiltration of multiple liters of wetting solu-
tion, permissive postoperative discharge, and selection
of unfit patients [20].
A COMPARISON OF THE BodyTite
PLATFORM AND THE Renuvion/J-PLASMA
SYSTEM
BodyTite
Introduction
The BodyTite RFAL system was introduced in 2008,
with FDA approval in November 2016. Initially, the
178 Neinstein & Funderburk
technology was denied approval, in 2011, but after the
introduction of the technology internationally, the tech-
nology was improved, and clinical data were obtained,
thereby earning the device its FDA approval. Various
size handpieces utilizing the BodyTite platform,
including FaceTite, NeckTite (available internationally),
and AccuTite, have since been introduced, for applica-
tion in smaller body regions.
Device design
The BodyTite platform contains a RF generator and con-
nects to a bipolar handpiece. A display screen is
included on the platform, which provides continuously
updated data regarding the internal and external tem-
peratures and the amount of energy delivered. Via the
display screen, internal and external temperature cutoffs
can be preset. The international version allows a practi-
tioner to enter the desired power, up to 70 W. Table 1
provides temperature and wattage settings in several
published studies. A foot pedal facilitates delivery of
RF energy. The platform also produces audible temper-
ature alerts to guide the practitioner without viewing
the display screen [43,44].
The handpiece has a silicon-coated cannula, which
emits RF energy from a distal, uncoated portion. The tip
of the cannula is protected to minimize thermal injury
in the form of end dermal hits. This cannula slides below
the surface of the skin and emits positively charged RF cur-
rent. A separate external electrode glides on the surface of
the skin and functions as a negatively charged electrode
[44]. Both electrodes have temperature sensors, allowing
precise measurements of the temperature at the level of
the FSN and the overlying skin.
The international handpieces have aspirating can-
nulas. This feature is not available with the US devices,
and suction is performed separately with a nonthermal
liposuction cannula.
Mechanism of action
The RF current flowing between the positive internal
electrode and the negative external electrode is coagula-
tive within approximately 1 cm to 2 cm of the internal
electrode. The thermal energy dissipates as it flows to-
ward the larger external surface electrode. This allows
a greater thermal effect on the FSN and deep dermis
than on the overlying skin. Biopsies of treated areas
demonstrate a coagulative, ablative effect on the under-
lying adipose, connective, and vascular tissues (see
Table 1). Skin tightening is produced by both coagula-
tion and contraction of the FSN as well as dermal
enhancement by nonablative thermal stimulation
[11,43,44].
Safety mechanisms of the BodyTite system
Multiple safety features are built into the BodyTite sys-
tem to minimize the risk of thermal injury.
Temperature monitoring: real-time temperature
monitoring shuts off RF energy delivery at the preset
maximum internal and external temperatures. The de-
vice begins to apply energy again when the temperature
drops below the set point. This allows maintaining
epidermal and deep tissue temperatures at the prese-
lected temperatures for the desired treatment time.
Temperature surge protection: the platform moni-
tors the rate of temperature rise and delivers full RF po-
wer only if the tissue is being heated at or below 20 C/
cm3/s. The RF energy is decreased if the temperature
rises between 20 C to 35 C and is halted if the rate ex-
ceeds 35 C/cm3/s. This decreases the risk of thermal
injury by rapid overheating.
Thermal containment: RF energy flows in a direc-
tional pattern between the internal cannula electrode
and the external electrode. This protects structures
deep to the internal electrode from heat.
Audible feedback: an audible signal is delivered via
the platform, signifying that RF energy is being deliv-
ered. A different signal pattern is delivered when the in-
ternal or external temperature has reached the preset
cutoff temperature. Signals also are given for loss of
contact from the external electrode and temperature
surges. This audible feedback enables the practitioner
to focus on the treatment site rather than the display
monitor.
Cannula design: the internal cannulas are coated
with silicone with only a distal unprotected portion
for RF transmission. This prevents thermal injury at
the access site and allows delivery of energy in a predict-
able pattern. Each cannula also has a protected tip to
minimize thermal injury in the form of end dermal hits.
Outcomes
Multiple peer-reviewed studies have been published
supporting the effectiveness of the BodyTite platform
in skin tightening and establishing the safety of the sys-
tem (see Table 1). The initial case series, an in vivo study
on soft tissue contraction, was published in 2009 [11].
This study showed that RFAL-induced temperatures of
69 C applied to the sept fascial network via the
BodyTite handpiece produced mean soft tissue contrac-
tion of 33%. Various body regions were tested,
including abdominal wall, hips, outer and inner thighs,
arms, flanks, and male breasts. Treatment parameters
included a 40 C external temperature cutoff and
treatment ranging from 20 W to 50 W, depending on
TABLE 1
Compilation of Data from Clinical Studies Using Radiofrequency Skin-Tightening Devices (InMode and Renuvion/J-Plasma)
Body Mean Age Radiofrequency
Reference Study Type Device Area Patients (Range in years) Treatment Control Settings Outcomes Complications
Paul and Case series BodyTite Abdomen, 20 43.9 (17–56) BodyTite None 20–50 W, 40 C Biopsies with destruction None
Mulholland hip, thigh, alone and coagulation of
[11], 2009 arm, flank, adipocytes and
breast adipose tissue;
photographic
evidence of
improvement in
contour and
contraction
Blugerman Case series BodyTite Abdomen, 23 38.8 (19–59) BodyTite None 35–40 W, 40 C Body contour None
et al [45], thigh 1 SAL improvements in all
2010 patients; at 6 wk,
13.9% linear
contraction
12 wk, 24.3% contraction
MR imaging with
persistence of

Advances in Skin Tightening with Liposculpture

reparatory process at
3 mo
Ahn et al [48], Case series FaceTite Face neck 42 (28–70) FaceTite None 10–15 W 5-point satisfaction None
2011 alone (depending scale 5 4.6 Significant
on region), tightening of the brow,
38 C–40 C lower lid fat, and malar
pads at 3–4 wk with
improvement over next
6 mo Cheek, jawline,
and neck tightening
clinically apparent in all
Paul et al [44], Case series BodyTite Abdomen, 24 39.7 (19–52) BodyTite None 40–70 W, 8%–15% linear One seroma treated
2011 hip alone 38 C–42 C contracture on table. with closed serial
At 6 mo, 12.7%–47% aspiration
linear contracture
Duncan [47], Case series BodyTite, Arm 12 (29–68) BodyTite None 30–35 W, 38 C 50% reduction in vertical One required
2012 Face Tite alone height of skin laxity; revision of
distal arms 35%–36% depressed
reduction; proximal access scar
arms 32%–34%
reduction

(continued on next page)

179
 180
Neinstein & Funderburk
TABLE 1
(continued )
Body Mean Age Radiofrequency
Reference Study Type Device Area Patients (Range in years) Treatment Control Settings Outcomes Complications
Hurwitz & Smith [51], Case series BodyTite Arm, 17 40.2 (22–59) BodyTite None 40–70 W At 12 wk, 6.2% reduction One seroma. 4
2012 abdomen,  SAL (depending of abdominal patients with
thigh on region), circumference, 4.4% transient focal
40 C thigh, 9.2% arm areas of
Mean vertical contraction induration treated
7.9% abdomen, 3.6% with massage
thigh, 2.4% arm and later therapy
Theodorou Case series BodyTite Abdomen, 97 37.6 BodyTite None 35–40 W, Patient satisfaction 82% Major complications
et al [50], flank, 1 PAL 38 C–42 C for degree of skin (infection,
2012 thigh, arm, tightening, 85% for seroma, adverse
back body contouring result med effect,
Independent surgeon significant burn)
grading: 74.5% good 6.25%; minor
to excellent contour complication
improvement, 58.5% (periportal burn,
good to excellent skin- end hits) 8.3%
tightening result
Duncan [12], Prospective, BodyTite Abdomen 12 40.2 (20–61) Half Half with 45 W, 38 C Area reduction at 6 wk: Two patients with
2013 randomized abdomen SAL 25.8% with nodularity
with alone BodyTite 1 SAL vs persisting at 1 y
BodyTite 10.3% with SAL alone
1 SAL Area reduction at 1 y:
34.5% with
BodyTite 1 SAL vs
8.3% with SAL alone.
Continued contraction of
10.6% over 1 year with
BodyTite vs loss of 2%
SAL alone
Theodorou Case series BodyTite Arm 40 40 (25–64) BodyTite None 35 W, Reasons for choosing One full-thickness
and Chia [49], 1 SAL 38 C–40 C BodyTite: 65% local burn near elbow;
2013 anesthesia, 55% early 1 seroma
return to work, 47%
degree of skin
tightening;
postoperative: 45% no
pain on infiltration,
35% minimal, 15%
moderate, 5%
significant pain; pain
with RF: 39% no pain,
41% minimal, 18%
moderate, 2%
significant; 6 mo
postoperatively 38%
extremely satisfied,
19% very satisfied,
30% satisfied, 13%
not satisfied;
independent surgeon:
contour improvement
8% excellent, 72%
good, 18% moderate,
2% poor; skin
tightening 11%

Advances in Skin Tightening with Liposculpture

excellent, 46% good,
38% moderate, 5%
poor
Chia et al [46], Prospective, BodyTite Arm 10 33.6 (18–48) BodyTite Aggressive 38 W, 40 C 1 y: surface area None
2015 randomized 1 SAL subdermal reduction of anterior
liposuction arm 15% with
1 SAL BodyTite 1 SAL vs
10.9% for SAL alone;
posterior arm 13.1%
vs 8.1% for control
Linear anterior reduction
22.6% vs 17.8% for
control
Gentile [53], 2019 Case reports Renuvion/ Face, neck 3 53.7 (50–59) Renuvion/ None Photographic evidence of None
J-Plasma J- Plasma improvement for all
 fat patients
grafting
 peel

181
182 Neinstein & Funderburk
body area. Biopsies of the treated areas demonstrated
destruction and coagulation of adipocytes and adipose
tissue, disruption and coagulation of adipocyte mem-
branes, and coagulation of small blood vessels. Similar
biopsy results were obtained in a 2010 case series [45]
using BodyTite (35–40 W; 40 C temperature cutoff)
and SAL for skin tightening of the abdomen and thighs.
Body contour improvements were observed postopera-
tively in all patients with linear contraction at 6 weeks
(13.9%) and at 12 weeks (24.3%; P<.001 for both).
This study incorporated MR 3-dimensional (3-D)
imaging, which demonstrated a reduction of subcutane-
ous fat tissue in treated areas, and signals consisted
with a persistent reparatory process at 90 days
postprocedure.
A prospective, randomized, split-abdominal study
was published in 2013 [12] comparing the effectiveness
of BodyTite and SAL versus SAL alone in 12 patients.
Comparison of tattooed skin regions using Vectra 3-D
photographs and Canfield (Parsippany, New Jersey)
software at 6 weeks showed a 25.8% skin surface area
reduction using BodyTite and SAL versus 10.3% with
SAL alone. The effect at 1 year proved even more dra-
matic, with a 34.5% reduction with BodyTite and SAL
versus 8.3% with SAL alone. This study demonstrated
a 10.6% continued contraction over the year with Body-
Tite compared with a 2% loss with SAL alone. The only
complications noted were nodularity persisting after
1 year in 2 patients, and no patient voiced dissatisfac-
tion with the outcome of the procedure or required
revision.
Another prospective, randomized study using the
BodyTite platform was performed in 2015 [46]. In
this split-arm study, BodyTite (38 W; temperature cutoff
38 C–40 C), with SAL was applied to 1 arm, whereas
the other was treated with aggressive subdermal lipo-
suction with SAL. Fluorescent tattoo skin markings
were used to assess skin tightening at 6 months and
1 year. Comparison of the anterior arms at 1 year
showed a 15% reduction in measured surface area
with BodyTite plus SAL versus 10.9% for liposuction
alone. Posterior arm surface area reductions measured
13.1% (BodyTite 1 SAL) versus 8.1% (liposuction
alone). All patients were satisfied with the operation
and there were no complications.
Similar effectiveness in tightening of the skin of the
arms was demonstrated in a 2012 case series of 12 pa-
tients treated with the BodyTite platform [47]. Use of
the BodyTite platform (30–35 W; 38 C temperature cut-
off) with either BodyTite or FaceTite handpieces
resulted in 50% average reduction in the vertical height
of pendulous arm skin laxity measured with tattooing
and Vectra imaging. The proximal upper arms showed
a total reduction of 35% to 36%, whereas the proximal
arms had a 32% to 34% mean reduction. In this study, 1
patient required revision of a depressed access scar.
A 2011 case series [48] demonstrated the effective-
ness and safety of BodyTite application for the face
and neck. Using the FaceTite handpiece with the
BodyTite platform (12–15 (watts [W]), cutoff temper-
ature 38 C –40 C; nasolabial folds and lower face 10
W–12 W, 38 C–40 C temperature cutoff; cheeks 2.5
W–3.5 W, 38 C–40 C temperature cutoff; and fore-
head and lower lids 10 W, 38 C–40 C temperature
cutoff), a high degree of patient satisfaction was ob-
tained. The average overall patient score on a 5-point
scale was 4.6, with 5 very satisfied and 4 somewhat
satisfied. Biopsies demonstrated localized coagulative
necrosis of subcutaneous fat, fibrous tissue coagula-
tion, and noncoagulative thermal restructuring of
adjacent reticular dermis. The surgeons noted signifi-
cant tightening of the brow at 3 weeks to 4 weeks
with improvement over next 6 months. Cheek,
jawline, and neck enhancements were noted along
with improvements in the nasolabial folds. There
were no complications and all patients were satisfied
with the degree of tightening achieved.
A patient survey of 40 patients treated with BodyTite
for arm skin tightening (35 W; 38 C–40 C temperature
cutoff) examined the reasons patients had for choosing
the BodyTite procedure; 65% were interested in under-
going a procedure with local anesthesia rather than a
general anesthetic and 55% cited early return to work.
After the procedure, 80% of patients responded that
they had minimal to no pain on infiltration, and 80%
had minimal to no pain with RF application. At
6 months postoperatively, 38% of patients were
extremely satisfied, 19% were very satisfied, 30% were
satisfied, and 13% were not satisfied with the proced-
ure. In this study, there was 1 full-thickness burn near
the elbow and 1 seroma.
Length of procedure
Depending on the thickness of the body areas to be
treated, the BodyTite system takes approximately 30 mi-
nutes to 45 minutes per treatment area. Multiple body
areas often are treated. The time to heat each region at
the target temperature varies in the published literature,
ranging from 1 minute to 2 minutes [11,44,45,49,50]
up to 5 minutes to 10 minutes [47]. Other endpoints
include lack of resistance, palpable warmth, mild ery-
thema, and uniformity with thermal imaging devices
[11,12,47,49].
 Advances in Skin Tightening with Liposculpture 183

Complications
The number of published complications with the cur-
rent iteration of the BodyTite platform is low, with the
majority minor complications that required little to
no intervention (see Table 1). In the largest case series
of BodyTite patients published to date [50], 6.25%, of
patients experienced a major complications (classified
as infection, seroma, adverse effects from medication,
and clinically significant burns outside of port entry
sites). The rate of minor complications (periportal
burns or end heats, which required no intervention)
was 8.3%.
In their 2011 case series of 24 patients with BodyTite
application to the abdomen and hips, Paul and col-
leagues [44] reported 1 seroma treated with closed serial
aspiration. One patient of 12 in a 2012 case series of
BodyTite for arm tightening had a depressed access
scar requiring revision [47]. Another 2012 study[51]
of 17 patients treated with BodyTite to the arms,
abdomen, and thighs had 1 seroma requiring an
indwelling catheter for 1 week, and 4 patients reported
transient focal areas of induration treated with massage
and low-level laser therapy. Persistent nodularity after
BodyTite use was noted in 2 patients at 1 year in a
2013 abdominal wall study of 12 patients [12]. One
full-thickness burn near the elbow and 1 seroma were
reported in a 2013 case series of 40 patients treated
with BodyTite for arm skin tightening [49].
Contraindications
Contraindications to BodyTite include patients who are
medically unwell, excessively overweight, and/or have
unrealistic expectations. Other exclusion criteria from
clinical studies have included pregnancy, breastfeeding,
severe skin laxity, smoking, inability to attend postoper-
ative appointments, history of prior liposuction to the
area of study, open sores or lesions in the treatment
area, pacemaker or internal defibrillator, recurrent her-
pes simplex or zoster, Fitzpatrick VI skin classification,
Crohn disease or abdominal hernia for abdominal
wall treatment, body dysmorphic syndrome, and blood
dyscrasias [12,45,47,49,50].
Costs
An estimate of the costs associated with the BodyTite plat-
form was published in 2018 [52]. These costs, in US dol-
lars, are presented in Table 2 alongside those of the
Renuvion/J-Plasma system (senior author’s (RN) data).
Renuvion/J-Plasma
Introduction
The Renuvion/J-Plasma device received FDA approval
in 2012 for cutting, coagulation, and ablating soft tis-
sue. The device represents a new approach to electrosur-
gery, whereby plasma flows into the application site for
only a brief interval and then disperses out, thereby
providing precise, predictable effects [53].

TABLE 2
Financial Considerations for the Clinical Use of Radiofrequency Skin-Tightening Devices (BodyTite and
Renuvion/J-Plasma)
BodyTite Renuvion/J-Plasma
Simple economic model (financial assumptions)
Device platform $205,000 $65,000
Disposable handpiece $200 $380
Down payment $40,000 $10,000
Lease rate 5% 5%
Lease term 36 mo 36 mo
Cash revenue $7000 $7000
Cash on cash returns analysis (financial assumptions)
Patient revenue $7000 $7000
Disposable $200 $380
Lease payment/mo $4925 $1000
Profit $1875 $5620

InMode data per Theodorou and colleagues [51], 2018. Renuvion/J-Plasma data per senior author’s experience.
184 Neinstein & Funderburk

TABLE 3
Pros and Cons of Radiofrequency Skin-Tightening Devices (BodyTite and Renuvion/J-Plasma)
BodyTite Renuvion/J-Plasma

Pros Cons Pros Cons

Thermal sensors measure Tissue being treated must Rapid heating of treatment Higher potential for
epidermal temperature be maintained at goal site subcutaneous
and cutoff RF energy temperature for 1–2 min emphysema/crepitus
when temperature for maximal contraction
exceeds predetermined
level
Directional flow from Time-consuming process Tissue surrounding site No thermal sensors on
internal to external remains at much cooler device
electrodes prevents temperature, resulting in
damage to deeper rapid cooling after
structures application of energy
through conductive heat
transfer
Monitors rate of Limited power output in Energy focused on heating No predetermined safe
temperature rise; if tissues with higher the FSN; allows level for cutoff of energy
significant spike occurs, impedance, such as fat immediate soft tissue
energy delivery stops contraction without
(temperature surge unnecessary heating of
protection) the full dermis
Measures and controls Smooth skin allows better Plasma energy directed to No audible feedback
tissue impedance, contact with external path of least resistance sensors from platform
delivering RF energy electrode in 360 manner. Allows for temperature
only when there is full treatment without need monitoring
contact of the external for user to redirect flow
electrode with the skin of energy
As subdermal temperature Skin lubricating gel needed Maintain consistent power No temperature surge
rises, the impedance output over wide range protection
falls and, if fall is of impedances
precipitous, shut offs the
energy
Physician can set the Low current of waveform
parameters of RF energy allows dispersal before
and cutoff temperature energy able to penetrate
as well as high and low deep into tissue. Allows
internal tissue tissue heating with
impedance to limit minimal depth of effect
epidermal heating
Audio feedback for Low current prevents
temperature monitoring tissue from being
overtreated with multiple
passes (as tissue
treated, impedance
increases)
Multiple handpieces and Variety of other clinical
sizes available uses, that is,
rhinophyma,
ligamentous release,
skin cancers, elevation
of flaps
 Advances in Skin Tightening with Liposculpture
Device design
The Renuvion/J-Plasma system consists of an electrosur-
gical generator unit, a handpiece, and supply of helium
gas. The generator delivers RF energy to an electrode in
the handpiece. Helium gas is passed over the energized
electrode, which generates helium plasma. This allows
heat to be applied to tissue by the production of plasma
through the ionization and rapid neutralization of the
helium atoms. A portion of RF energy used to energize
the electrode and generate the plasma also passes to the
patient and heats tissue by passing current through the
resistance of the tissue.
The current device also includes a retractable blade,
which enables greater versatility, including cosmetic
uses, such as the treatment of rhinophyma [53].
Mechanism of action
The Renuvion/J-Plasma system utilizes cold helium
(atmospheric) plasma via a gas ionization process to
produce a stable, focused beam of energy. Electrosur-
gical energy flows into the application site for a brief in-
terval then quickly disperses out. This results in precise,
predictable effects on the skin and underlying connec-
tive tissue. Rapid heating of the FSN, and subsequent
skin tightening, occurs as the plasma rapidly gives up
energy to the surrounding tissue with each pass of the
device. The release of helium gas in the subdermal tis-
sue helps to rapidly dissipate the accumulated thermal
energy. There is no net flow of electricity around the
body, so no return electrode is required [53,54].
Unlike the BodyTite system, the energy from the
Renuvion/J-Plasma device flows in a 360 manner
from the electrode with energy taking path of least resis-
tance. Untreated, energy-naïve tissue is preferentially
treated with each subsequent pass of the device, because
it has lower impedance than treated tissue [55]. By pass-
ing the device through the FSN, most of the energy is
directed to the surrounding FSN, allowing maximal
skin contraction. In contrast to the BodyTite platform,
which relies on more time-consuming bulk tissue heat-
ing, the Renuvion/J-Plasma system achieves soft tissue
coagulation and contraction by heating tissue to tem-
peratures greater than 85 C for 0.040 seconds and
0.080 seconds with rapid cooling by conductive heat
transfer [56].
Safety mechanisms
The Renuvion/J-Plasma system uses nonconductive cur-
rents and a proprietary RF waveform, which has a much
lower current than typical RF devices. These properties
limit thermal tissue spread, thereby protecting both
185
underlying structures and the overlying dermis. Low-
current energy also helps prevent overtreating tissue
when performing multiple passes. The heating and
rapid cooling properties of the Renuvion/J-Plasma sys-
tem allow skin tightening via focused coagulation of
the surrounding FSN without unnecessary heating of
the full thickness of the dermis.
Outcomes
Published, peer-reviewed evidence of the Renuvion/
J-Plasma system is limited compared with the BodyTite
platform (see Table 1). A 2019 case series of 3 patients
treated with Renuvion/J-Plasma for nonexcisional con-
touring of the face and neck showed photographic
evidence of contour improvement in all patients at
3 months [53]. There were no reported complications.
Another patient was treated successfully with the device
for rhinophyma, demonstrating the versatility of the
device.
Length of procedure
For the experienced user, the time to treat the abdom-
inal skin is approximately 12 minutes, the thighs or
arms 7 minutes, and the neck 5 minutes (senior au-
thor’s experience).
Complications
There are no reports to date of complications resulting
from the Renuvion/J-Plasma system, but published
data are limited.
SUMMARY
The development of safe and effective skin-tightening
devices for the delivery of energy to the FSN and over-
lying dermis has revolutionized body contouring sur-
gery. With energy via RF or plasma, both preexisting
skin laxity and skin laxity that results from traditional
liposuction and the removal of the underlying adipose
tissue can be treated. The technology has evolved
rapidly over the past decade with emergence of multiple
devices and handpieces of various sizes coming to mar-
ket. These devices enable energy application to
numerous body sites, including the face, neck, torso,
and extremities, giving the practitioner a large number
of procedures to offer patients. This should be of
interest particularly to aesthetic surgeons as the patient
demand for awake, safe, and effective aesthetic im-
provements continues to rise. The pros and cons of
the BodyTite and Renuvion systems are outlined in
Table 3.
186 Neinstein & Funderburk
As outlined in this article, the scientific literature
gives validation to the application of these energy
devices:
 Objective measurements with preoperative and
postoperative circumferential measurements and
3-D imaging systems consistently show significant
skin tightening with energy application to the FSN.
 Patients express a high degree of satisfaction after
skin-tightening procedures with energy devices,
both for the skin-tightening result and for the level
of comfort during the procedure.
 Awake skin-tightening procedures are able to be per-
formed without the need for general anesthesia and
its attendant risks.
 In multiple studies, independent plastic surgeons
have evaluated the results of skin-tightening proced-
ures and have deemed the vast majority effective.
 The BodyTite system features several safety mecha-
nisms, including thermal sensor cutoffs, temperature
surge protection, and audible feedback.
 The Renuvion/J-Plasma system offers quick and
effective treatment to multiple body sites with direct
heating of the FSN, without the need for prolonged
heating associated with the BodyTite system.
 The costs associated with device rental and hand-
pieces with the BodyTite and Renuvion/J-Plasma
system are recouped with few applications per
month.
With any energy application, the utmost consider-
ation must be given to patient selection and proper
surgical technique to obtain a desirable result and to
ensure patient safety. The current skin-tightening de-
vices have remarkably few published complications,
with the majority requiring either local wound care or
seroma aspiration or drainage. Along with their signifi-
cant effect on skin laxity, this makes these devices an
ideal tool for the interested aesthetic surgeon.
DISCLOSURE
Dr R. Neinstein is a paid speaker and shareholder for
Renuvion.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found
online at https://doi.org/10.1016/j.yacs.2020.01.012.
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