Dr. Richard Gentile is a board-certified facial plastic surgeon practicing in Northern Ohio. He is recognized as the leading advocate for using energy-based devices during facial and neck rejuvenation and lectures world-wide on many of the techniques he has developed.

Richard D. Gentile, M.D., M.B.A.

Energy has been applied in some form to tissue since the beginning of recorded history. The practice of applying heat to tissue with the use of cauters was used for thousands of years as an invaluable method of controlling hemorrhage. Continuous improvement of methods for utilizing the beneficial effects of heat on tissue eventually led to the development of the basic concepts of electrosurgery as we know it today. 

One of the newer entrants to the energy-based device market is Renuvion® (Apyx Medical, Clearwater, Fla.) which is powered by cold helium plasma. We have been using this advanced energy device in our practice for about three years and find it to have certain favorable features.

 Its unique energy — helium plasma and proprietary radiofrequency (RF) — allows for precisely controlled delivery of heat to tissue, with minimal thermal spread and rapid heating with near-instantaneous cooling in part aided by the cooling effect of helium gas under the skin (in subdermal applications) which allows for shorter duration of activation, and therefore less diffusion of heat to the skin. Studies show that during subdermal use of Renuvion, temperature at the surface of the skin does not rise by more than 4°C and because of this, external temperature-monitoring is not required although it may be beneficial for treatment observation for uniformity of treatment as well as a safety monitor. 

Ablative skin rejuvenation for deep rhytids and elastosis has in the past involved both laser and chemical alternatives. For years phenol peeling and trichloroacetic acid were frequently used.

The pendulum switched to lasers in about 1994 when we purchased our first laser. The pendulum then swung away from ablative treatments with newer technologies featuring fractionated or hybrid lasers. 

Renuvion represents the first fractional device available for highly ablative skin rejuvenation. The U.S. Food and Drug Administration (FDA) approval for Renuvion is for delivery of RF energy or helium plasma for cutting, coagulation and ablation of soft tissue. A more specific indication for rhytid reduction is being pursued by the company in order to facilitate marketing for wrinkle reduction.

The skin rejuvenation aspects of this technology were first noted by Dr. Joseph DeLozier, a plastic surgeon in Nashville, Tenn., who first introduced the freehand technique. With Renuvion treatment energies of 20% to 40% with helium flow rates of usually 4, are utilized for the treatment. Treatment can be done with either a painting, pulsed or fractionated method. The pulsed and fractionated treatment techniques were developed by the author

 and represent a method of reducing energy treatment levels (morbidity) as this is a highly ablative treatment. One to two passes are typically done. 

Renuvion is also helpful for treatment of Rhinophyma (phymatous rosacea).

Subdermal Facial & Neck Contouring with Skin Tightening 

We introduced concepts and techniques for subdermal facial and neck rejuvenation in 2007 after being introduced to subdermal laser lipolysis concepts of skin tightening

 at about the same time. These concepts were first considered controversial but have subsequently evolved with the advent of temperature-regulated monopolar, bipolar and ultrasound devices that all work in the same paradigm for thermal mediated fibro liposculpture with remodeling. 

The evolution of devices has advanced from SmartLipo lasers to Precision TX to ThermiRF to FaceTite and now RF-helium plasma. Higher levels of temperature monitoring are implemented on the more recent devices but only the Renuvion device has a self-limiting ability to avoid temperature extension to the dermis which can result in thermal burns. 

We utilize the subdermal facial and neck approach to reduce fat and tighten skin and soft tissue in the submental area mandibular angle and the jowls. Procedures can be done as a stand-alone (device only) technique or combined with minimally invasive surgical techniques (hybrid procedures). The settings for the device for subdermal procedures differs from the settings on the skin rejuvenation technique. Usually 75% power and 1.5 liters of helium flow are used. The subdermal technique also involves more passes as typically six subcutaneous passes are done in the midline followed by left and right cervical and then left and right facial if indicated for jowl reduction. 

Thermoplastic techniques for rhytidectomy and the holy grail of the “Shrink Wrap” facelift continues to evolve and improve with the advent of new technologies such as Renuvion RF-Helium Plasma. While these techniques are not positioned to replace facelift surgery, they do offer a suitable alternative to those patients who refuse rhytidectomy surgery.

1. Gentile RD. Cool Atmospheric Plasma (J-Plasma) and New Options for Facial Contouring and Skin Rejuvenation of the Heavy Face and Neck. Facial Plast Surg. 2018;34(1):66-74.

2. Gentile RD. Renuvion/J-Plasma for Subdermal Skin Tightening Facial Contouring and Skin Rejuvenation of the Face and Neck. Facial Plast Surg Clin North Am. 2019;27(3):273-290.

3. Gentile RD, Mccoy JD. Pulsed and Fractionated Techniques for Helium Plasma Energy Skin Resurfacing. Facial Plast Surg Clin North Am. 2020;28(1):75-85.

4. Gentile RD. Smartlifting ™-A technological Innovation for Facial Rejuvenation. Cynosure white paper available www.dcanavan.com/PDFS/Collateral/Compendium.pdf. accessed 4-24-4014.

5. Gentile RD. Smartlifting ™-A technological Innovation for Facial Rejuvenation. Lasers in Surgery and Medicine 41 Supplement 21 July 2009.

6. Gentile RD. LaserFacialSculpting™ Minimally Invasive Techniques for Facial Rejuvenation Utilizing the Smartlipo™ Nd:YAG Laser February 1, 2010 http://66.36.229.213/live/cynosureapp/Smartlipo_MPX_TP/smartlook_smartlifting/921-0187-000_r2_LaserFacialSculptingWP.pdf. Accessed 4-27-2014

7. Gentile RD. SmartLifting™ fiber laser-assisted facial rejuvenation techniques. Facial Plast Surg Clin North Am. 2011 May;19(2):371-87

8. Gentile RD. Laser-assisted neck-lift: high-tech contouring and tightening. Facial Plast Surg. 2011 Aug;27(4):331-45

Disclosures: Dr Gentile is a medical advisory board member of Apyx Medical.

Articles

Dr. Richard Gentile’s experience and research with cold helium plasma adds to the growing body of knowledge of thermoplastic techniques for rhytidectomy. 