Features
Non-surgical body contouring
Today’s patient wants to avoid the downtime and potential complications associated with surgery. Non-invasive devices provide alternative solutions for body contouring procedures. Practitioners give their reports
RADIOFREQUENCY-ASSISTED LIPOSUCTION: While traditional liposuction is the gold standard for surgical body contouring, energy-assisted treatments provide added benefits such as skin tightening, writes Mr Lucian Ion
Radiofrequency-assisted liposuction (RFAL) has primarily been introduced to fill the gaps with problems that suction-assisted liposuction (SAL) can’t address. In firmer tissue, sometimes SAL can be more difficult to use. In gynaecomastia, there is the effort to minimise scarring and therefore energy-assisted treatments can provide improvement as well as some skin tightening.
RFAL focuses on selective tissue destruction and removal using electromagnetic energy. It works by liquefying the tissue. It attempts to generate skin retraction and reduce volume. We want the container to match the volume left behind. It is computer-controlled with internal and external electrodes, real-time monitoring for the surface temperature and impedance to improve safety.
By heating the reticular dermis and the area just below, the device changes the characteristics of the skin. I prefer not to describe this as skin tightening or contracture because we generate a different response. The main actions are liquefaction and coagulation of the smaller blood vessels. But the long-term effect comes from the following nine months of the wound-healing sequence.
In terms of infiltration, I tend to use the same parameters as for SAL, using a wet technique. I am on the cautious side with energy. But you can control the energy you provide. You set the power which will determine the energy, the temperature limit and the impedance limit.
In larger volumes, never treat all layers. Under the skin’s surface and the fat shell, there has to be something soft for the skin to look normal, otherwise we will generate problems with transfer from lying down to standing. After liposuction, patients might look fine when you lie them but when they stand up, strange shapes appear in the area. Some surgeons do the extraction first with SAL and follow it up with RF heating.
Consultation
When I consult with these patients and decide whether to use RF versus another technique, I need to ask myself what I’m trying to achieve. I’m mainly trying to achieve skin suspension. Skin tightening is slightly overrated because the appreciation of a firm body is an amalgamation of support and elasticity of the outer layers. It is not purely related to the characteristics of the skin.
But naturally, we also want to try to improve the skin. By using RF—and to some extent laser-assisted liposuction—we can improve the natural zones of adhesions, with better contact between the skin and the underlying tissues leaving sufficient elasticity that it doesn’t look bizarre. We need to remember that aggressive treatment in a young patient who will fluctuate in weight might lead to distortions because of the way the fat is limited in expanding.
But one of the key points is that the treatment has to be performed without causing damage. In my practice, it has enhanced the endpoint in situations where I found SAL or power-assisted liposuction (PAL) to be limiting.
All energy techniques go through the same pathway of adult wound healing. We are not generating elastic collagen production, because we hit the tissue with a different form of energy—there’s not much hope that we will create elasticity where none was before. And we can’t thicken the dermis, such as in a patient with very thin, weakened skin.
I have used the technique for most areas of the body and have also treated lipodystrophy which is a relatively difficult tissue. Maximum temperature at the start should be around 37°. It can be brought up to 42° only in select cases. If you start readily with high temperatures it will be more likely to produce damage than to help patients.
Following the procedure, the amount of bruising generated—even with large-volume extractions—is quite limited. Around three
months post-operatively, you can get a nice impression of tightening. I do not think this is skin tightening. I do not see the same effect with LAL, because the volumetric fibroplasias may be generated better with RF—there is more heat at the cannula tip than with the laser.
HIV-related lipodystrophy is one of the most difficult areas to treat but I have found nice long-term results. With sun-damaged and aged skin, you may see a pebbling effect. If you’ve done the treatment carefully, this should disappear as the wound healing progresses. But you have to be aware of the potential side effect and be able to reassure patients that it will heal if it occurs.
I have used RFAL with endoscopic abdominoplasty to thin the flap. It will not create so much damage in the skin that it suffers necrosis with undermining. When harvesting for a fat transfer for the breasts, with simple SAL and fine technique you can get a nice contouring effect. In areas with moderate laxity and patients don’t want incisional techniques, it is an alternative to SAL or PAL.
I have found the technique useful in difficult zones where you can see the tissue adhesion areas are the troublemakers. You want to break these and to allow the tissue to remodel around. Patients who have had previous treatments with SAL but want more sculpting can be treated with the RFAL.
It can also be used for large-volume treatments. However, these are a poor indication for liposuction of any type. Liposuction won’t get them to weigh less. But if the SAL part of the treatment is correct, it can be used nicely. I have used it to help reduce the need for tightening in someone who doesn’t want periocular scars.
Complications
I have had three complications with RFAL concerning burns. If you want to perform RFAL, the point where it can create damage is where you advance the tip of the cannula when it’s active. I would suggest starting treatment by advancing the cannula without the foot on the pedal—just put your foot on the pedal when you withdraw. This way you never have the hot point at the very tip that can damage the tissues. You will also be able to get the tissue to loosen up, enabling back and forth movement with less risk.
In terms of limitations and learning curve, safe cut-off is not a guarantee. You have to be aware and careful of what you’re doing and the operation attention is fundamental.
Mr Lucian Ion is a consultant plastic surgeon who practices in Harley Street, London
