HBOT THERAPY

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CLINICAL CASE REPORT
UNDERSEA & HYPERBARIC MEDICINE
Hyperbaric oxygen for the treatment of severe
subcutaneous and mediastinal emphysema
after Renuvion/J-Plasma therapy®
Christopher Winstead-Derlega MD, MPH; Justin Allen DO
Center for Hyperbaric Medicine and Environmental Physiology, Department of Anesthesiology,
Duke University Medical Center, Durham, North Carolina U.S.
CORRESPONDENCE: Justin D. Allen – justin.d.allen@duke.edu
_________________________________________________________________________________________________________________________________________________________________
ABSTRACT
Winstead-Derlega C, Allen J. Hyperbaric oxygen for the treatment of severe subcutaneous and me-
diastinal emphysema after Renuvion/J-Plasma therapy®. Undersea Hyperb Med. 2022 First Quarter;
49(1):563-567.
Subcutaneous and mediastinal emphysema are known complications of liposuction and body sculpting
procedures. Treatment options are limited, and recovery is often prolonged. We discuss a case of severe
subcutaneous and mediastinal emphysema after a skin-tightening procedure involving helium gas.
The patient received one treatment of hyperbaric oxygen and was followed until symptom resolution.
We review the known literature on hyperbaric oxygen therapy as a treatment for subcutaneous
emphysema. ❚
KEYWORDS: helium; hyperbaric oxygen therapy; pneumomediastinum; Renuvion/J-Plasma therapy®;
subcutaneous emphysema
_________________________________________________________________________________________________________________________________________________________________
INTRODUCTION
Cosmetic rejuvenation and body contouring pro-
cedures are increasingly popular [1]. Traditional
surgical options have been displaced by minimally
invasive outpatient procedures, with enhanced
cosmetic outcomes and rapid recovery times [2,3].
While technologies and techniques vary, a popular
procedure is Renuvion/J-Plasma® therapy, a Federal
Drug Administration (FDA) approved proprietary
technology for cutting, coagulation and ablation
of soft tissues (Aypx Medical Corporation, Clear-
water, Florida) [2-4]. The device, which consists of
a hand piece, electrosurgical generator unit, and
pressurized helium gas source, employs interval
focused beams of ionized helium gas to create a
stable cold atmospheric plasma [3].
Renuvion/J-Plasma therapy for cosmetic skin
tightening is a prevalent but off-label use. Plasma
beam application in the subcutaneous and sub-
dermal plane induces rapid heating of collagen,
resulting in denaturization, contraction, and sub-
sequent skin tightening. The subdermal plasma
heats local tissue to temperatures of 85°C for a
period of 0.04 to 0.08 seconds; the transfer of
energy induces collagen contraction to one-third
of its original length [2,3,5]. We report the first
known case of severe subdermal and mediastinal
emphysema following Renuvion/J-Plasma treated
with hyperbaric oxygen (HBO2) therapy. In addi-
tion, we review cases of subcutaneous emphysema
treated with HBO2.
CASE REPORT
A 54-year-old female presented to the hyperbaric
clinic with severe subcutaneous emphysema of the
head and neck, pneumomediastinum and pneu-
mopericardium. The patient’s past medical history
included diabetes, hypertension, hyperlipidemia,
and deep venous thromboembolism. Her rivarox-
aban was held one week prior to the scheduled
procedure.

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HBO2 FOR SEVERE SUBCUTANEOUS EMPHYSEMA – UHM 2022 VOL 49 NO 1
On the day prior to presentation the patient underwent upper
extremity skin tightening utilizing Renuvion/J-Plasma at an out-
patient dermatology clinic. Within minutes of initiating the proce-
dure the patient reported chest tightness and shortness of breath.
The procedure was rapidly aborted, and widespread facial and
neck edema was noted (Figure 1A). An EKG was obtained; and
needle aspiration on the chin was performed without changes
in the patient’s facial edema. An EKG was negative for acute
coronary syndrome. The patient was ultimately discharged home.
Within an hour of discharge, the patient experienced progres-
sively worsening facial, eyelid and neck edema, with severe dys-
pnea on deep inspiration (Figure 1B).
Winstead-Derlega C, Allen J
Figure 1
A – Patient immediately after procedure
B – Patient two hours after procedure
C – Patient immediately after HBO2
D – Patient six days after procedure (D)
NOTE: The patient supplied written permission for the use of her image.
She presented to a local emer-
gency department and was initially
treated with IV dexamethasone,
diphenhydramine, and piperacilin-
tazobactam.
On exam the patient exhibited
diffuse subcutaneous emphysema
with crepitus and pain through-
out the right upper extremity,
upper chest, neck and face. A
non-contrast CT scan of the head,
neck and chest revealed extensive
subcutaneous emphysema of the
neck and chest with pneumome-
diastinum and pneumopericar-
dium. There was no evidence of
pneumothorax (Figure 2).
Due to the concern for helium
exposure, the regional poison
control center was contacted; the
center recommended consultation
with a hyperbaric medicine ser-
vice. Simultaneously, a cardiothor-
acic surgeon was consulted given
the extensive amount of emphys-
ema. No surgical intervention was
indicated. The patient was placed
on 100% oxygen via non-re-
breather facemask and was trans-
ferred to a hyperbaric facility
for evaluation and treatment.
On arrival to the hyperbaric fa-
cility the patient had stable vital
signs, with no evidence of acute
respiratory distress. Clinical exam
demonstrated continued facial and
anterior neck subcutaneous em-
physema with palpable crepitus.
She was neurologically intact but
had notable dysphonia, dysphagia
and dyspnea. Initial blood testing
was remarkable for a leukocytosis,
9.9x10ˆ9/L, and hyperglycemia,
167 mg/dL.

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HBO2 FOR SEVERE SUBCUTANEOUS EMPHYSEMA – UHM 2022 VOL 49 NO 1
Winstead-Derlega C, Allen J
Figure 2
Saggital (A), frontal (B), and transverse (C) images of
non-contrast CT scan of the head, neck, and chest
demonstrating extensive subcutaneous emphysema,
pneumomediastinum, andpneumopericardium pre-HBO2.
(D) Chest film with diffuse subcutaneous emphysema.
The patient underwent a single hyperbaric oxygen treatment
at 2.82 atmospheres absolute (ATA) for 85 minutes, with a total
dive time of 148 minutes. During compression she had difficulty
with middle ear equalization and suffered mild right-sided otic
barotrauma. After the procedure, her subcutaneous edema and
pain improved but did not fully resolve. She was able to eat and
drink without pain, and the dyspnea on inspiration was resolved.
She was discharged home in stable condition immediately after
HBO2 (Figure 1C). The patient reported symptom resolution on Day 6
(Figure 1D). The patient provided written informed consent to
report her case, including consent for publication of her images.
DISCUSSION
Subcutaneous emphysema is the presence of gas within the soft
tissue. The etiology is discovered with clinical history. Practitioners
should consider infection from gas-forming organisms, iatrogenic
or traumatic perforation of cutaneous or mucus structures, per-
foration of hollow organs, and respiratory tract trauma [6]. Patients
may present with localized or diffuse pain, edema and crepitus.
Emphysema often involves the
soft tissue planes of the neck,
causing dysphagia and dysarthria.
Hamman’s sign, described as a
crunching sound associated with
the heartbeat, may be heard on
auscultation and should raise the
suspicion for pneumopericardium
and/or pneumomediastinum. In
rare cases tension physiology can
complicate subcutaneous emphy-
sema and compromise the cardio-
respiratory system; this is partic-
ularly concerning in the presence
of continuous positive-pressure
ventilation and respiratory system
trauma [7]. In all cases the diagno-
sis is clinical but is assisted with
radiographic imaging.
Treatment is generally conser-
vative and involves rapid identifi-
cation and removal of the source
followed by evaluation for pneu-
mothorax [6]. Identification of the
source of air will determine appro-
priateness of intervention. In most
cases needle aspiration or tube
thoracostomy is not indicated [6].
Patients are observed while they
breathe room air or are placed on
100% oxygen to accelerate air dif-
fusion. Rare cases of tension sub-
cutaneous emphysema causing
thoracic outlet obstruction and
hemodynamic collapse may re-
spond to skin incisions and sub-
cutaneous drains [7,8].
Subcutaneous emphysema is a
well-described complication from
traditional methods of cosmetic
body contouring procedures, in-
cluding pneumomediastinum after
liposuction [9,10]. To our knowl-
edge only two cases of subcuta-
neous emphysema after J Plasma

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therapy have been reported [11,12]. Lim et al. de-
scribe a patient with a case of subcutaneous em-
physema after J Plasma therapy who responded to
normobaric oxygen; symptoms resolved after 72
hours of observation [12]. While most cases of
subcutaneous emphysema involve air – which
is made up of approximately 78% nitrogen, 21%
oxygen, 1% trace elements – emphysema after J
Plasma therapy likely involves both air and helium
gas. Interestingly, Dr. End in 1967 proposed the
use of hyperbaric oxygen in a case of subcuta-
neous emphysema after accidental injection of
helium gas into a foot [13]. The patient received
“decompression incisions,” warm-water soaks, anti-
biotics, and a tetanus vaccination, with reso-
lution after 10 days of observation [14].
It is notable that helium is the lightest of the
noble gases, with a density of 0.179 g/L, in com-
parison to air 1.293 g/L and oxygen 1.429 g/L at
standard temperature and pressure (STP) [15].
Helium is safe and metabolically inactive; it rapidly
diffuses and has a low solubility at STP. Helium
has been used safely as an additive breathing gas
in saturation and deep-sea diving activities for
decades [16]. As an inert gas, helium itself does
not pose any specific health concerns; however,
the extent of paratracheal subcutaneous emphy-
sema, pneumomediastinum, and pneumoperi-
cardium was concerning for airway compromise
and a potential risk for arterial or venous gas
embolization. Due to these concerns and the
patient’s clinical symptoms, we elected to pro-
ceed with hyperbaric oxygen therapy.
HBO2 is the therapeutic application of 100%
oxygen in chambers pressurized above atmos-
pheric pressure. The mechanism of HBO2 is multi-
factorial. In accordance with Dalton’s law, HBO2
increases the partial pressure of oxygen in blood
by saturating the plasma, and thereby the sur-
rounding cellular tissue. HBO2 reduces intravas-
cular leukocyte adhesion and reduces soft-tissue
edema and inflammation [17]. We also hoped that
compression would alleviate symptoms caused
by the volume of gas in the pericardial and medi-
HBO2 FOR SEVERE SUBCUTANEOUS EMPHYSEMA – UHM 2022 VOL 49 NO 1
Winstead-Derlega C, Allen J
astinal spaces via Boyle’s law (P1V1=P2V2), where
V1 represents the volume of subcutaneous gas
at sea level (P1), and V2 is the volume of gas at
treatment pressure (P2), 2.82 ATA. If it is assumed
1 liter of gas was present at 1 ATA, then at 2.82
ATA the volume would be 0.35 L, or a 65% reduc-
tion in volume. With the extent of subcutaneous
and intrathoracic air the patient presented with,
we expected some improvement in clinical symp-
toms from the reduction in gas volume via com-
pression and gas diffusion out of these spaces.
As stated, the treatment approach to sub-
cutaneous emphysema varies. Treatment must be
specific to the etiology of pathology and should
focus on excluding infection and reversing the
cause. In divers, subcutaneous emphysema may
result during pulmonary barotrauma of ascent.
The U.S. Navy Dive Manual recommends shallow
hyperbaric oxygen recompression, after excluding
pneumothorax, to approximately five or 10 feet
for variable lengths of time depending on symp-
tom resolution [18]. Other cases of subcutaneous
gas responding to HBO2 have been reported
(Table 1). Balas et al. describe a case of right-thigh
subcutaneous emphysema possibly related to
a snake bite which was treated with HBO2 [19].
AL-Njadat et al. describe a laceration which
developed subcutaneous emphysema which was
treated with HBO2 [10]. A case of presumed self-
inflicted upper-extremity subcutaneous emphy-
sema received two sessions of HBO2 after surgical
exploration [21]. Iniesta-Sanchez et al. describe a
unique case of retinal detachment repair utilizing
sulfur hexafluoride, SF6, and possibly octafluoro-
propane, C3F8, for intraocular gas tamponade; this
resulted in recurrent and persistent periocular
edema which responded to numerous HBO2 treat-
ments [20].
CONCLUSION
This case illustrates a rare complication for an in-
creasingly common off-label cosmetic procedure.
We believe the application of hyperbaric oxygen
relieved the patient’s acute complaints and

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Winstead-Derlega C, Allen J
accelerated patient recovery. Patients of Renuvion/
J-Plasma therapy should be aware of the potential
complications of this novel procedure. Given the
extensive subcutaneous emphysema, pneumome-
diastinum and pneumopericardium, there may be
a theoretical risk of arterial gas embolism if a blood
vessel is damaged during the procedure. We be-
lieve HBO2 should be considered in specific cases
and discussed with experts in hyperbaric medicine.
n
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REFERENCES
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___________________________________________________________________________________________________________________________________________
Table 1: Literature supporting the use of HBO2
to treat unusual cases of subcutaneous emphysema.
AUTHOR AGE GENDER PROCEDURE/INJURY GAS ANATOMIC LOCATION TREATMENT (tx) OUTCOME
Balas et al. 16 female unknown, possible air right thigh HBO2 3ATA, resolution after 5 days,
1974 snake bite 60 min, 15 tx 5 treatments
___________________________________________________________________________________________________________________________________________
Iniesta-Sanchez 40 female retinal detachment SF6, C3F8 right periorbital HBO2 3 ATA, complete resolution
et al. 2016 repair 300 minutes after 4 months
35 treatments, qd
___________________________________________________________________________________________________________________________________________
Al-Njadat 18 male 2cm laceration air left upper extremity HBO2 2.4 ATA, resolution after HBO2
et al. 2020 100 min, 1 tx
___________________________________________________________________________________________________________________________________________
De Roeck 17 female multiple puncture air left upper extremity, HBO2 unknown resolution after HBO2
et al. 2019 wounds, presumed neck ATA, unknown
self-inflicted time, 2 tx
___________________________________________________________________________________________________________________________________________
Kim et al. 2019 32 female liposuction air face, pneumomedia- NBO2 5L/min via improved on day 3,
stinum, bilateral mask, 6 days discharged on day 7
pneumothoraces
___________________________________________________________________________________________________________________________________________
Lim et al. 2020 48 female liposuction helium face, thorax, abdomen, NBO2 5L/min via resolution & discharge
and J-Plasma® pneumomediastinum nasal cannula, 3 days on day 3
___________________________________________________________________________________________________________________________________________

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Widespread subcutaneous emphysema after J-plasma
therapy. Am J Cosmet Surg. 2020. 38(1): 24-26.
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Available from: https://www.navsea.navy.mil/Portals/103/
Documents/SUPSALV/Diving/US%20DIVING%20MANUAL_
REV7.pdf?ver=2017-01-11-102354-393.
19. Balas P, Oeconomidis M, Tzamouranis D, Tripolitis A.
Spontaneous subcutaneous emphysema. Am J Surg. 1974.
127(6): 755-756.
20. Iniesta-Sanchez DL, Romero-Caballero F, Aguirre-
Alvarado A, et al. Management of orbital emphysema
secondary to rhegmatogenous retinal detachment repair
with hyperbaric oxygen therapy. Am J Ophthalmol Case
Rep. 2016. 1: 26-30.
21. De Roeck L, Van Assche, L, Verhoeven, V, et al. Progressive
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Winstead-Derlega C, Allen J