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17 Laser Assisted Body Contouring
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superior skin redraping [13, 22–24]. The effect can be compared to the application of chemical peels on the skin where
the controlled skin injury is created in order to achieve skin
tightening. Overall result on the skin can be observed after
several months (approximately 4–10weeks) [13, 17, 25, 26].
Majority of patients seeking body contouring via liposuction
have moderate skin excess. In general, patients are not prepared to undergo skin excision procedures due to the visibility (regardless of how hidden it is) of the resulting scar.
Laser-assisted liposuction offers an excellent alternative for
those who do not have clear indications for skin resection
procedures. During preoperative consultations, it must be
clearly stated that skin tightening happens over time. Although
the subjective impression of skin tightening has been observed
from the implementation of the laser lipolysis, Di Bernardo
and Reyes were rst to clearly prove the skin tightening effect
[26]. They treated one side with laser- assisted liposuction and
the contralateral one with conventional liposuction. Retraction
of skin was measured with photo-documentation and nonpermanent ink marks. Skin tightening was measured with an
elasticity device. The results were signicantly better on the
side treated with laser. Unfortunately, clear indications and
mathematical models of skin tightening do not exist to date.
As a result, there is a learning curve for the surgeons in order
to achieve sufcient experience on the amount of the skin
retraction after the laser-assisted liposuction.
Signicant decrease in blood loss can be observed during
the laser-assisted vs. conventional liposuction. Goldman
reported coagulated blood vessels in fatty tissue in the histological analysis of lipolytic tissue [15]. Various reports conrmed the diminished blood loss during the laser-assisted
liposuction. [14, 26, 27] Abdelaal and Aboelatta conducted a
study on 56 patients. One side was treated with conventional
liposuction and the other side was treated with the laserassisted liposuction. Blood loss was calculated from the
lipoaspirates. The results showed that the blood loss reduction was greater than 50% for the side treated with laser.
Reduction of blood loss is one of the reasons for the faster
recovery. With laser-assisted liposuction, the risk of postoperative fatigue and weakness due to the postoperative anemia
is diminished.
Most of the patients seeking liposuction also struggle with
supercial aesthetic imperfections like cellulite. It has been
reported that cellulite affects 85% of adult females [28]. The
cause of cellulite is multifactorial and is highly variable among
the patients and depends on the genetics, diet, and physical
activity. Despite that, the residual effect in appearance stays
the same. The subcutaneous fat herniates from the hypodermis
in the dermis due to the laxity of the brous septa [29].
Goldman etal. were the rst to report signicant improvement
by combining 1064 nm laser lipolysis with autologous fat
transfer with 84.6% patient’s satisfaction rate. The patients
scored the result to be good or excellent [30]. It remains
unclear to what extent the laser energy alone was responsible
for the result. In 2016, Petti etal. reported combined treatment
with 1440nm Nd:YAG laser lipolysis with 1000 micron directional side-ring ber optic laser system for simultaneous
treatment of both cellulite and lipodystrophy. They reported a
high satisfaction rate among both surgeons and as well as the
patients treated [31]. These ndings suggest that different
wavelengths used during the laser- assisted liposuction could
be better at addressing different aesthetic issues [31, 32]. A
small study was conducted in 2009 by Palm and Goldman on
nine patients and 11 treated sites. One side was treated with
laser-assisted liposuction and the contralateral side with
mechanical disruption of fat. The patient did not report any
difference but the surgeons noticed improvement on the lasertreated side [33]. The authors have not conducted their own
controlled research but can report high satisfaction rate among
the patients regarding cellulite improvement with the use of
laser during liposuction procedures. Also, the laser lipolysis
alone without aspiration has been used in our facilities to treat
skinny patients with localized cellulite.
The use of laser during the liposuction procedures enables
the use of smaller cannulas. The fat is being liqueed during
the laser lipolysis and in the melted form can be suctioned
through smaller cannulas. The liquefaction of fat combined
with smaller cannulas enables the treatment of smaller areas
as well as the areas that are highly brous and where the fat
is enclosed in smaller compartments. That advantage is especially signicant when treating postliposuction irregularities,
face, male chest, knees, hips, and back. Laser lipolysis alone
without suction has been reported with the same success at
6months follow-up [34]. Nevertheless, due to possible complications that can result from the necrotic tissue, authors do
not advocate the use of laser lipolysis alone without suction
for larger volumes of liqueed fat.
The use of smaller cannulas, and the fact that the fat is
disrupted by the application of laser energy and not by
mechanical manipulations along with the coagulation effect
of the laser, enables faster and smoother recovery for patients.
Multiple lipomas or large lipomas are an ideal indication
for the laser-assisted liposuction. Surgical extirpation of
lipomas results in unwanted scars. With laser lipolysis incision marks are minimal and results are satisfactory. Treatment
with laser does not guarantee total extirpation but given the
benets of minimal scarring, the patients are generally open
to this treatment. Preoperative assessment of the lipoma
should be done with ultrasound and/or cytological evaluation
or tissue biopsy to exclude malignant alteration.
Last, but not least—the fact is that laser energy and not
the surgeon’s hand are responsible for the fat disruption.
Once familiar with the procedure, it is easier to perform the
laser-assisted liposuction than the conventional one. The
suction of the melted fat should be smooth without too much
involvement of the surgeon’ strength.
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Z. Žgaljardić and I. Žgaljardić
17.5 Disadvantages andSpecic
Complication
The most common concern regarding the use of lasers in the
subcutaneous area is the overheating of the tissue and subsequent burns and skin necrosis. It is important to bear in mind
that the injury came from the subcutaneous place. Therefore,
if any blistering occurs in the postoperative period, it will
denitely result in a full-thickness burn although initially it
may appear as a supercial one. Due to the scarring of the
full-thickness burn, this has to be avoided at all costs. To
prevent this complication, some machines come equipped
with an internal thermometer. Noncontact external thermometer can be used but it is highly unpractical and unreliable.
Some authors suggest cold external compressions to avoid
overheating of the dermis from the subcutaneous space [14].
For beginners with this technique, we advise the use of lower
energy and discontinuous wave to avoid the accumulation of
too much energy in one place. As with the aspiration in conventional liposuction, to avoid aspiration of too much fat in
one place, the cannula must always be in motion. The same
is true with the laser ber. The best way to avoid this complication is to constantly move the laser ber. When working in
the tissue that is brotic, sometimes you encounter resistance
and have to keep the ber at once place until the laser energy
disrupts the blockage. Therefore, we do not advise laser use
in that kind of tissue for the beginners. At the same time, the
nondominant hand should always be over the laser beam in
order for the surgeon to be able to asses subjectively the
external temperature of the skin.
Given all that, the most important disadvantage with the
use of this technique is the surgeon’s learning curve. As previously stated, at the beginning we advise the use of lower
energy and discontinuous wave with the use of machine with
internal thermometer or external measurements until the surgeon’s experience allows him to control the temperature with
his nondominant hand. The same goes for the prediction of
skin tightening. Unfortunately, there are no scientic data to
precisely tell when to rely on the skin tightening effect of
laser and when to advocate for skin resection surgeries. Until
enough experience is obtained the dubious cases should be
avoided. In general, better skin tightening is achieved in
younger patients. Patients who previously underwent bariatric surgery procedure and/or have had a massive weight loss
are usually not candidates in whom you can expect good skin
retraction.
Due to the liquefaction of fat, necrosis is possible when
the melted fat is not aspirated from the treated area.
Physiological process of debris removal through macrophage activity is possible in reasonable amount. If those
capacities are exceeded, the residual nodules, lumps, and
contour irregularities can be observed. The aspiration of the
substrate diminishes that risk although not completely. The
remaining necrotic tissue results in mass formation. On the
histopathological report, it has been described as a uidlled pseudocyst with characteristics of foreign-body granuloma [35]. Smaller lumps and subcutaneous hardening could
successfully be treated with a postoperative massage or
triamcinolone- acetonide injection.
Although coagulation of small vessels is expected during
the laser-assisted liposuction and the risk of fat embolization
is minimized, surgeon performing the procedure has to bear
in mind the possibility of such occurrences [36].
In 2015, Shin and Chang reported a rhabdomyolysis
case with acute kidney injury after the laser-assisted liposuction [37].
17.6 How weDo it
As with any cosmetic surgery procedure, preoperative evaluation is essential. Evaluation of the skin excess should be
performed. As stated previously, dubious cases should be
avoided initially until enough experience is gathered.
Liposuction is not a weight-reducing surgery but a body contouring surgery. We recommend weighing the patient in our
facilities before the procedure as well as on follow-ups to
avoid any disagreement with the patient regarding the result
that could emerge from signicant weight changes unrelated
to the procedure itself. Hence liposuction should be done
only in patients with a stable weight. Specic informed consent for the laser-assisted liposuction should be given to the
patient. Preoperative markings (Fig.17.1a, b) should be done
before the procedure with patient in the standing position.
Specic markings should be made on the contour irregularities. The procedure is done in the supine position on the
operative table so all the contour imperfections are lost due
to the lack of gravitational force. This is why surgeons should
rely on his or her preoperative markings.
The authors recommend disinfection of the operative eld
in the standing position with the operative table covered with
the sterile garment to avoid compromising the operating eld
during the surgery. Some surgeons prefer to rotate the
patients but we recommend the supine position for all body
regions except pure back or buttocks liposuction. The anks
and tights are done with the non-dominant hand controlling
the contour.
Preoperative bacterial prophylaxis is done with intravenous 2g of cephazolin.
There are many authors that advocate tumescent anesthesia but we prefer general anesthesia for full-body procedures.
The tumescent anesthesia, in our opinion, is comfortable for
both the patient and the surgeon only for the treatment of
localized, small areas of lipodystrophy, or cellulite.
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a
b
Fig. 17.1 (a, b) Preoperative markings
Inltration pump is used to deliver the Klein’s solution (in
cases that are done under general anesthesia pure 0.9%NaCl
with epinephrine can be used in the 1L/1mL 1:1000 ratio to
avoid lidocaine toxicity but still to achieve the vasoconstriction) in order for the inltration to be uniform. Uneven distribution of the inltration solution can lead to changes in
contour irregularities (that is why it is important to believe
your preoperative markings). The insertion of the laser beam
should be delayed until the skin blanching due to the vasoconstriction is achieved (usually 5–15min). When multiple
areas are treated, usually by the end of the inltration of the
last area, the area that has been inltrated initially can undergo
laser. The inltration is made in two layers, starting from the
deep fat compartment and ending supercially. If the treated
area is sagging and skin retraction is expected, larger area
should be inltrated superiorly. That area should be treated
only with laser with no suction afterward. Energy applied on
the larger area results in greater skin retraction (especially
important for the male chest and knees) (Fig.17.2).
Small entry points are made with a No.11 blade in such a
way that it will enable the coverage of a larger region. It is
always better to make additional entry points than to struggle
with inadequate access because it can have a great impact on
the nal result.
The authors have been using 1470nm diode laser for the
past 10 years. Laser settings are as follows: energy 12W
Fig. 17.2 The arrows show the area that should be treated with laser
energy only to achieve a proper tightening effect and subsequent lifting
of the whole male breast
(10W for the upper arms, 6 W to treat more delicate areas
like face area and the submental fat), the pulse wave is continuous except for the treatment of the facial area. In that
case, the pulse wave is discontinuous. We suggest for the
beginners to lower the energy settings and work with the
pulsed mode. The sliding of the laser ber should be smooth
and continuous with constant movement. Few seconds of
stalling at one area can be done when there is a lot of brous
tissue that gives resistance in an area. It is crucial to con-
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stantly follow the laser ber with the nondominant hand controlling the external temperature. The lysis should be started
in the deeper layer following the same rules as for the liposuction—radially over the targeted area from the entry point.
The underlying muscle and its sheet should not be damaged
to avoid the possible rhabdomyolysis as well as postoperative pain and discomfort. Once the deeper layer is treated,
one should move toward the more supercial layer. Pinch
test should be performed at this point to evaluate the liquefaction of subcutaneous fat. The laser lipolysis is nished
when a satisfactory pinch test is achieved and there is only
minimal resistance in sliding of the ber.
There have been attempts to summarize the applied
energy over the targeted area over the years that can help
beginners in evaluating the amount of energy per region.
Raynaud et al. performed a retrospective analysis on 534
cases and calculated the mean amount of energy and inltration applied to different regions [38]. In 2018, Ali published
the results of a prospective study calculating the amount of
energy in order to propose detailed parameters to ensure
safety and efcacy. They report the following average cumulative energies: 2000–2500J for the chin, 8000–12,000J for
the arm, 5000–6000J for male gynecomastia on each side,
4000–5000J for anks, 10,000–14,000J for the abdomen,
12,000–18,000 J for the back, 8000–15,000 J for saddle
bags, 10,000–14,000J for the thigh and 800–2000J for the
knee. The study was conducted with Smart Lipo triplex
model system that uses Nd: YAG as an energy source [39].
Those ndings can help beginners estimate the amount of
energy needed for the successful treatment of different
regions. In author’s personal experience, larger amount of
energy should be applied when working with the diode laser.
Nevertheless, care must still be taken and the opposite hand
should always stay alert for the localized temperature rise
regardless of the given settings.
After the liquefaction process is done with the laser, the
procedure continues with standard suction of the melted
fat. Although there are many reports on lysis only, without
suction, the authors do not advise it for larger areas. If a
small area is treated due to lipodystrophy or contour irregularities (mainly after previous surgeries) as well as a cellulite treatment, laser lipolysis only can be performed. This
stage, in opposite to the conventional liposuction, should be
smooth. Suction is carried out from deep to supercial
changing cannulas from larger to smaller diameter. Once
again, a pinch test should be continuously performed
(Figs.17.3, 17.4, and 17.5) to assess the amount of remaining fat. For the same reason, surgeon should also monitor
the canister with the emulsied fat (per region) to avoid
uneven suction.
Once the suction is completed, the authors advise the
supercial application of the laser energy alone in order to
stimulate the shrinkage of the existing and formation of new
collagen in the remaining brous tissue and the dermis.
When working with a one-directional beam, the end of the
Z. Žgaljardić and I. Žgaljardić
Fig. 17.3 Pinch test at the beginning of the procedure
Fig. 17.4 Pinch test showing there is still fat in the treated region
Fig. 17.5 Pinch test at the end of the procedure
ber should be facing the deep dermis opposite to the radial
laser source that can be directed straight forward and still
reach the targeted area supercially. Care must be taken to
control the external temperature.
In full body procedures, we recommend giving corticosteroids in high therapeutic doses during the procedure to
minimize the risk of postoperative swelling.
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17.7 Tips andTrick inPerforming theHighDenition Liposuction
In authors opinion, in order to achieve a natural looking
result, high-denition should be performed in individuals
that already have accentuated underlying musculature but
are not able to get rid of the stubborn fatty envelope.
In obtaining the high-denition result, preoperative markings are essential. Markings should be done in the standing
position. Besides the standard markings that are done before
any liposuction, muscle borders should be outlined precisely
asking the patient to contract the specic muscle or doing a
specic movement. At the end of the procedure, the focus of
interest is the tendinous parts of the abdominal musculature
that should be highlighted. More heat should be applied over
those parts to promote the collagen stimulation in the underlying brous septa that would result in visible muscle denition.
Only a laser ber can be used to obtain that effect. If the entry
point for the liposuction is not suited to reach those parts, an
additional small entry can be made to suit the surgeon’s hand.
The patients seeking this kind of procedure are usually athletic
with minimal to moderate amounts of the subcutaneous fat.
Since the fatty layer is not thick, care must be taken not to
injure the underlying muscle or to scratch the aponeurosis since
it can result in increased postoperative pain and discomfort.
Patients looking for high denition appearance are highly
demanding and seek perfection. The technique is not recommended for inexperienced surgeons. Overheating of the tissue where only a thin layer of fat can be found can easily
result in thermal damage of the dermis, subsequent necrosis,
and scarring since the most of the energy is then absorbed by
the connective tissue and the dermis. That kind of complication is unacceptable for the patients and although you can
manage the complication successfully most likely you will
not end up with a satised client.
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Fig. 17.6 Application of laser energy in the tissue superior to the
breast with the laser beam pointed towards the dermis
treatment. The goal is to sculpt the chest with high denition for men. Preoperative markings of the pectoral muscle
should be done. Many of the patients suffering from this
condition have some kind of breast sagging. Visible scars
on the male chest are unfavorable. In order to resolve the
sagging, laser energy should be applied on a wider area in
order to allow the healing process to retract the excessive
skin adequately. If substantial sagging is present, we recommend wide inltration of the tumescent solution, not
only in the breast, but also superiorly, almost up to the
clavicle (see Fig.17.2). That wider area should be treated
with laser energy (Fig.17.6) only to achieve the breast lifting effect. No suction should be done outside the male
breast if there is no indication (the lateral chest wall should
also be addressed to obtain a pleasing appearance of the
male thorax).
17.9 Ending theProcedure
17.8 Tips andTricks inTreating Male
Gynecomastia/Pseudogynecomastia
Reports say that around 32–65% of adult men suffer from
gynecomastia [40, 41]. With the increasing incidence of
obesity, there is also increasing trend in male pseudogynecomastia. When there is no signicant amount of the glandular hypertrophy, laser-assisted liposuction is an ideal
If large volumes of emulsied fat have been removed, the
authors suggest leaving the entry points open to allow the
drainage of the residual uid. Additionally, we advise putting
a penrose drainage through the entry points. The dressings are
put on the entrance wounds for protection. If the amount of the
work done allows, the wound can be closed with one stitch.
Also, in cases of high-denition laser liposuction, we advise
closing the wound to minimize the visibility of the scar.
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Z. Žgaljardić and I. Žgaljardić
17.10 Postoperative Garments
Compressive dress (suits made from a exible, yet strong
enough material) is applied over the treated area and customed individually according to the patient physical structure. If high-denition laser-assisted liposuction is
performed, we advise putting additional compression over
the tendinous parts with an adhesive bandage. The proper
postoperative garment is essential in obtaining a good result.
Compressive dresses and garments are worn for 7 days.
Following this, the postoperative garment is worn for
another 2weeks. Adhesive bandages are also left during the
rst postoperative week.
17.11 Postoperative Instructions
Showering is allowed after the rst week. Hot water is not
allowed during the rst 3weeks after the surgery to avoid
vasodilatation and edema. Compressive garments should
work as previously described. We recommend oral antibiotics usually second-generation cephalosporin during the rst
5days after the surgery. Also, when larger areas are treated,
we strongly advise postoperative observation during the rst
12–24h not only to monitor the patient but also to educate
him or her in what is normal to expect in the postoperative
period. If the whole body was treated, a signicant amount
of uid can be squeezed out during the rst few hours after
putting on the compression garment. In our experience, to
avoid unnecessary calls or check-ups soon after the surgery,
it is better to have those patients in your facility for a few
hours. If a signicant amount of swelling is expected, postoperative oral corticosteroids could also be administered.
After the rst postoperative week, the authors advise
patients to perform lymphatic self-drainage (especially after
treating lower extremities) with a roller. Stronger lymphatic
massages can be performed after 3weeks if there is a signicant accumulation of liquid in the treated area. In that case,
seroma formation must be excluded by ultrasound or diagnostic aspiration of the suspected area is preferably done
with 18G needle.
In the beginning, all of the patients struggle with the garment until they get used to it. It is of greatest importance to
explain to them that they are put in place to ensure the best
result possible and to facilitate the skin tightening effect.
Usually, well-educated patients are more likely to be
compliant.
17.12 Results
The authors have used diode 1470nm for the past 10years
and all patients seeking liposuction have been treated with
the laser-assisted one. Patient satisfaction rate has risen since
the implementation of laser, especially in terms of skin
retraction and postoperative discomfort.
Figures 17.7, 17.8, 17.9, 17.10, 17.11, 17.12, 17.13,
17.14, 17.15, 17.16, and 17.17 show early and late outcomes
Fig. 17.7 (a) Before (b)
After 7days
a
b
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a
c
b
d
Fig. 17.8 (a) Before (b) After 7days. (c) Before. (d) After 7days
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Z. Žgaljardić and I. Žgaljardić
a
c
b
d
Fig. 17.9 (a). Before (b) After 7days. (c) Before. (d) After 7days. (e) Before. (f) After 7days
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ef
Fig. 17.9 (continued)
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Z. Žgaljardić and I. Žgaljardić
a
e
b
f
c
d
Fig. 17.10 (a) Before (b) After 3weeks. (c) Before (d) After 3weeks. (e) Before. (f) After 3weeks
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