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The treatment plan included liposuction of the patient's back before renuvion.The subdermal renuvion portion of the procedure was performed using the renuvion precise handpiece (hp) which includes an extendable and retractable electrode.During the procedure, the distal nose cone of the hp handle developed a split which allowed the shaft of the hp to shift position and expose the electrode.The surgeon noticed the damage to the hp and continued to use the damaged hp during the procedure.This caused breakage of the exposed electrode.The portion of the electrode distal to the break remained in the patient.The patient is doing well and stable.There are no adverse effects on the patient's long-term health; however, once the patient's swelling has subsided, the doctor intends to remove the fragment using ultrasound mapping.The device settings were 80% power and 4.0 lpm of helium flow.The doctor reported doing 8 retrograde passes 2 cm apart at an intermediate treatment depth.The manufacturer's surgical system standards state that when performing retrograde only passes, to use 3 -5 passes per area.The instructions for use (ifu) for the precise handpiece was reviewed as part of the investigation, and it states not to use the hp if there is any damage or breakage to the hp.A review of the device history record for the manufacturing lot provides assurance that the device was manufactured to specification.The returned hp was subject to investigation in accordance with company procedures.The engineering evaluation confirmed the nose cone and a slider used to extend the blade are broken.The electrode retraction mechanism is non-functional as a result and is stuck in the extended position.
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