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32 Numerical Methodology forEvaluation ofResults inLiposuction
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Fig. 32.1 Bidigital maneuver measure of the thickness of the cutaneous fold in the mediumaxillary line and abdomen
493
overaspiration, thus reducing the risks of complications such as irregularities, nodules, and adherences. At one month after surgery, when approximately 80% of the
edema has already regressed (Hunstad and Aitken 2006), the patient is again submitted to the measure of the cutaneous folds, and the values are compared against
the preoperative data.
Results
Table 32.1 lists the preoperative and postoperative measurements in centimeters of
the skinfolds of 20 patients. The mean measurements in centimeters of the skinfolds
and the standard deviation for each patient were evaluated.
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R. H. de Almeida et al.
Table 32.1
Comparison between the standard measurements and the mean values in centimeters
of the skinfolds analyzed in the study of liposuction, for each patient
Preoperative period Postoperative period (6 months)
Patient
Standarda (cm) Meanb (cm) STDEVcStandarda (cm) Meanb (cm) STDEV
1 1.0 3.75 1.66 1.4 1.95 0.77
2 1.7 3.45 2.02 1.2 1.77 0.42
3 1.2 3.70 1.69 0.7 1.54 0.62
4 1.3 4.42 2.02 X 2.02 0.79
5 2.0 5.36 2.25 2.3 2.65 0.62
6 0.9 3.27 1.51 X 2.26 0.34
7 1.1 2.9 1.33 1.9 2.1 0.63
8 1.5 3.16 1.00 1.6 2.22 0.50
9 2.0 3.56 1.54 2.0 2.28 0.34
10 2.3 3.56 1.28 1.5 1.87 0.65
11 1.2 4.05 1.94 1.1 2.1 0.73
12 1.0 3.2 1.4 1.0 1.74 0.8
13 2 4.05 1.41 1.6 2.22 0.54
14 2.5 5 1.88 2 2.23 0.39
15 1.5 4.68 2.68 1.8 2.5 0.55
16 0.8 3.07 1.73 1 1.9 0.55
17 1.2 4.73
2.72 1 1.55 0.64
18 1.2 4.02 2.06 1.2 1.85 0.52
19 1.7 3.18 1.67 1.5 1.7 0.47
20 x 4.25 1.77 1 2 1
Mean//STDEV 386 0.69 2.02 0.29
a
Standard: measured in centimeters from the skinfold corresponding to the medium-axillary line,
between the ninth and tenth ribs
b
Mean: arithmetic mean among all measurements, in centimeters, for each patient
c
STDEV: standard deviation. The standard deviation is calculated by using the n-1 equation.
Finally, x is the sample mean of the data studied (value 1, value 2, etc.), and n is the sample size.
This function uses the following formula:
E
2
-
nxx-
1
c
Discussion
Ilouz (Illouz 1998) reported that complications in liposuction are divided into two
parts. The rst one includes surgical and systemic alterations and complications that
continue in the traditional technique (Illouz 1998). The second one includes unfavorable results and sequels, which are numerous and complex (Illouz 2006).
ab
cd
32 Numerical Methodology forEvaluation ofResults inLiposuction
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495
Patients want the best possible results from plastic surgery (Augustin etal. 1999).
Subjective evaluations can lead to conicting impressions between the surgeon and
the patient. The use of a quantitative method for analysis makes a more-objective
demonstration of the surgery results possible.
The method of measuring the skinfolds can be used during surgery to note thickness references for the abdominal and ank cutaneous folds after liposuction.
Another advantage of the here-described method is its ease in demonstrating the
eventual occurrence of ponderal gain with the increase in the subcutaneous tissue
through the comparison of the measures in the immediate and late postoperative
periods.
We have used this method in our service for the past 4 years with easy execution,
at low cost, and with satisfactory results. The method is safer for plastic surgeons
because it reduces conicts and improves doctor–patient relationships (Figs.32.2,
32.3, and 32.4).
Fig. 32.2 (a) Treatment areas in the abdomen. Pleat measurements of the skin in the preoperative
period. Front position (front view). (b) Treatment areas on the abdomen. Preoperative skinfold
measurements (oblique view). (c) Treatment areas in the abdomen. Pleat measurements of the skin
in the postoperative period. Front position (front view). (d) Treatment areas on the abdomen.
Postoperative skinfold measurements (oblique view)
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R. H. de Almeida et al.
a
b
c
de f
Fig. 32.3 (a) Treatment areas in the abdomen. Pleat measurements of the skin in the preoperative
period. Front position (front view). (b) Treatment areas on the back. Preoperative skinfold measurements (rear view). (c) Treatment areas in the abdomen. Skinfold measurements in the preoperative period (prole view). (d) Treatment areas in the abdomen. Pleat measurements of the skin
in the postoperative period. Front position (front view). (e) Treatment areas on the back.
Postoperative skinfold measurements (rear view). (f) Treatment areas in the abdomen. Skinfold
measurements in the postoperative period (prole view)
ab c
Fig. 32.4 (a) Treatment areas in the abdomen. Pleat measurements of the skin in the preoperative
period. Front position (front view). (b) Treatment areas on the back. Preoperative skinfold measurements (rear view). (c) Treatment areas in the abdomen. Skinfold measurements in the preoperative period (prole view). (d) Treatment areas in the abdomen. Pleat measurements of the skin
in the postoperative period. Front position (front view). (e) Treatment areas on the back.
Postoperative skinfold measurements (rear view). (f) Treatment areas in the abdomen. Skinfold
measurements in the postoperative period (prole view)
32 Numerical Methodology forEvaluation ofResults inLiposuction
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497
Summary
Liposuction is the standard method for lipodystrophy treatment. However, the
amplitude of areas to be treated sometimes makes it difcult to evaluate the perioperative results. Measuring the skinfolds is anatomical work that allows for making
pre-established mathematical comparisons for the patient. By applying this study
method, surgeons can make more-objective demonstrations and exert a higher level
of perioperative control over liposuction, which are associated with reducing patient
complaints, asymmetries, and levels of hypocorrection in their respective treatment areas.
References
Souza Pinto EB, Abdalla PCSP, Maciel CM (2005). História da lipoaspiração. In: Carrerão S,
Cardim V, Goldenberg D, eds. Cirurgia Plástica. São Paulo: Atheneu; cap.6.
Toledo LS, Giovannetti M (2003). Lipoaspiração e lipoenxertia nas deformidades do abdômen,
dorso e ancos. In: Mélega JM, ed. Cirurgia Plástica: fundamentos e arte- cirurgia estética.
Rio de Janeiro: Medsi. p.629-38.
Coleman WP (2000) 3rd. Powered liposuction. Dermatol Surg.; 26(4):315-8.
Pollack SV (1999). Liposuction of the abdomen. The basics. Dermatol Clin. 17(4):823-34.
Illouz YG (2006). Complications of liposuction. Clin Plast Surg. ;33(1): 129-63.
Illouz YG (1998). Lipesculpture et chirurgie de la silhouette. Chirurgie plastique reconstructrice
et esthétique. Encycl Med Chir Edidions Scientiques et Médicales. Paris: Elsevier. p.45-120.
Hunstad JP, Aitken ME (2006). Liposuction: techniques and guidelines. Clin Plast Surg.
;33(1):13-25.
Chang KN (2004). The use of intraoperative grid pattern markings in lipoplasty. Plast Reconstr
Surg.;114(5):1292-7.
Avelar J, Illouz YG (1986) Anatomia cirúrgica e distribuição do tecido celular no organismo
humano. In: Lipoaspiração. Rio de Janeiro:Hipocrates; p.45-57.
Duarte AC, Castellani FR (2002). Medidas antropométricas. In: Semiologia nutricional. São Paulo:
Axcel Books do Brasil; p.34-57.
Mendez BM, Coleman JE, Kenkel JM (2019). Optimizing Patient Outcomes and Safety With
Liposuction. Aesthet Surg J.; 39(1):66-82. doi: https://doi.org/10.1093/asj/sjy151.
Collins PS, Moyer KE (2018). Evidence-Based Practice in Liposuction. Ann Plast Surg.; 80 (6S
Suppl 6): S403-S405. doi: https://doi.org/10.1097/SAP.0000000000001325.
Chia CT, Neinstein RM, Theodorou SJ (2017). Evidence-Based Medicine: Liposuction. Plast
Reconstr Surg.; 139(1):267e-274e. doi: https://doi.org/10.1097/PRS.0000000000002859.
Augustin M, Zschocke I, Sommer B, Sattler G (1999). Sociodemographic prole and satisfac-
tion with treatment of patients undergoing liposuction in tumescent local anesthesia. Dermatol
Surg; 25(6):480-3.
Chapter 33
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Laser Lipolysis: Skin Tightening
inLipoplasty Using HPL Dual Diode Laser
MoisésWolfenson, LydiaMassakoFerreira, JoaquimFigueiredo,
andBrunaAlves
Abstract Background: To present the changes in the dimension of the skin, obey-
ing the safety parameters related to the energy accumulated in laser lipolysis procedures in different anatomical regions, using a double-wavelength diode laser device
(924 and 975 nm).
Method: A prospective, cross-sectional case series study included 552 patients
submitted to laser lipolysis for the treatment of facial and body contouring deformities between June 2008 and June 2019. Laser lipolysis was performed with a diode
laser device with two independently controlled wavelengths, one of them operating
at 924nm and the other at 975 nm, using tips of three sizes according to suitability
for small, medium, or large areas of treated adipose tissue. The measurements were
compared using the Wilcoxon test, at a signicance level of 0.05. The most important retractions occurred at the waist circumference, at the level of the umbilical
scar—measured with a tape measure before and 90 days after the laser—and the
second largest retraction at submental region: measured by parking meter in lines
L2 and L3, before the application of double laser and after 90 days.
Results: In all these patients, there was signicant skin retraction regardless of
the surgical site (face, breast adiposity, arms, or waist), and the only complications
that existed were erythema and edema that disappeared within 30 days after the laser.
Conclusion: The diode laser proved to be able to promote progressive and persistent skin retraction, obeying the proposed safety parameter.
Keywords Lipectomy/methods · Laser therapy · Plastic surgery
M. Wolfenson (*)
Avenida Boa Viagem, Recife, PE, Brazil
L. M. Ferreira · J. Figueiredo · B. Alves
São Paulo, Brazil
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_33
499© The Author(s), under exclusive license to Springer Nature
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M. Wolfenson et al.
Introduction
Almost all people have a body contour imperfection or deformity that causes discomfort or embarrassment. These deformities may result from normal and inevitable physiologic changes, such as those associated with repeated weight loss,
localized fat deposits, and aging laxity. Other deformities may be associated with
cosmetic failure of corrective procedures, such as conventional liposuction, plastic
procedures, or augmentation lipoplasty.
Until recently, lipoplasty was commonly associated with postoperative complications, including bruising, decreased hematocrit resulting from signicant blood
loss, scarring caused by cannula insertion and friction with the skin that may be
difcult or impossible to correct, or even sequelae such as changes in skin texture
and skin waviness, among others (Triana etal. 2009). These complications were a
challenge to plastic surgeons and served as a stimulus for the development of
devices that allow partial or even total correction of skin deformities and body contour and that have become increasingly safe. At present, laser lipolysis may be performed using a dual-wavelength diode laser to facilitate liposuction by nonaggressive
techniques.
The photothermal effect of laser irradiation on the hypodermis is used for heating fat cells, leading to membrane rupture, consequent release of intracellular lipase,
and fat liquefaction, which facilitates liposuction. In addition, the heating of brous
septa and reticular dermis causes tissue thinning, leading to an improved aesthetic
result. The photothermal properties of the laser light may also be applied for cauterizing small blood vessels, decreasing at the surgical site.
Photothermal effects have been used in the development of devices for laser
lipolysis operating at different wavelengths in the range of the absorption spectra of
fat, water, and other chromophore associations. The dual-wavelength diode laser is
one of the devices available for lipolysis. It operates at 924 nm, which is a wavelength specic for liquefying adipose tissue, and at 975 nm, which is a wavelength
that acts on collagen and elastin bers in the deep dermis. This system preserves the
epidermis, thus eliminating most risks associated with its use.
The use of devices for laser lipolysis requires attention during the surgical procedure regarding the total energy transmitted by the laser to each region of the body,
the so-called cumulative energy, for the best aesthetic result by the remodeling of
brous conjunctive tissue. The control of the cumulative energy is essential to
reduce risk of complications, such as necrosis, prolonged erythema, hyperchromic
skin patches, secondary bacterial infection, and dyschromia.
This topic has been studied to determine the safety parameters for preventing
treatment complications. The purpose of this study was to evaluate skin tightening
after laser lipolysis using a dual-wavelength laser operating at 924 and 975nm.
Even with excellent results in skin retractions on the face and body contouring
with the use of laser, for cases of excessive accidity, we have rhytidectomy and
abdominal dermolipectomy referred to as state of the art in our study.
33 Laser Lipolysis: Skin Tightening inLipoplasty Using HPL Dual Diode Laser
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Patients andMethods
This prospective, cross-sectional study was approved by the Institutional Research
Ethics Committee and performed in accordance with Resolution 196/96 of the
Brazilian National Health Council (Conselho Nacional de Saúde) and the Brazilian
Ethical Review System on Research Involving Human Beings. Written informed
consent was obtained from all patients before their inclusion in the study, and anonymity was ensured.
The study was conducted between June of 2008 and July of 2019. Participants
were recruited from consecutive patients meeting the study criteria referred by the
Plastic Surgery Outpatient Clinic of the Federal University of Pernambuco General
Hospital to the Multi-Aesthetic Clinic (Clínica Multiplástica) in Recife, Brazil, and
the study was sent and approved to the CEP of UFPE (Universidade Federal de
Pernambuco).
Inclusion criteria were skin laxity after plastic surgery, sequelae after primary
liposuction, submental adiposity, arm adiposity, gynecomastia, and laxity in the
area around the umbilicus. Exclusion criteria were previous fat grafting, laxity after
bariatric surgery with indication for plastic surgery, infection in general, diagnosis
of autoimmune diseases, and cancer.
The study included 552 patients. All these patients are women who used laser
lipolysis for the treatment of deformities of the face and body contour with a mean
age of 53.4 years (between 35 and 62 years) and a body mass index ranging from
18.5 to 24.9 kg/m2 and were included in the study and underwent laser lipolysis to
correct contour deformities.
Laser lipolysis was performed using a dual-wavelength diode laser (SlimLipo,
Palomar Medical Technologies, Burlington, Mass., licensed by the US Food and
Drug Administration and by the Brazilian Health Surveillance Agency) operating at
two wavelengths (924 and 975 nm) independently controlled for different output powers.
Three different tip lengths (80, 180, and 280 mm) were used, allowing treatment
of small (submental region), medium (brachial region), and large (ank and abdominal regions) areas of adipose tissue. Before the procedure, 10 × 10 cm areas
(100cm2) were marked on the skin with a bright green marker (Fig.33.1).
The circumference of each treated body region was measured carefully at three
time points (preoperatively, immediately after laser lipolysis, and on postoperative
day 90). For the face, three lines (lines 1, 2, and 3) were measured at the three time
points. Line 1 extended from the corner of the mouth (cheilion) to the lateral palpebral commissure (exocanthion) of the same side of the face; line 2 was constructed
from the central part of the chin region (mental protuberance) to the inferior insertion of the earlobe (otobasion inferius); and line 3 connected the right otobasion
inferius to the left otobasion inferius, passing through the submental area (Fig.33.2).
Photographic documentation with standardized views, taken from the same distance with the same camera (Sony Cyber-shot DSC-P10, Sony, Tokyo, Japan), was
also obtained from all patients at the three time points. A total energy dose of 5 kJ
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Fig. 33.1 Laser lipolysis performed in (above) the abdominal region showing one 10 × 10cm skin
area, with the diode laser programmed for a cumulative energy of 5 kJ, and (below) in a right arm
marked with two 10 × 10 cm skin areas, with the diode laser programmed for a cumulative
energy of 8 kJ
Fig. 33.2 Diagram
showing the position of the
lines used in measurements
of the face performed
preoperatively,
immediately after laser
lipolysis, and on
postoperative day 90.
L line
M. Wolfenson et al.
(5000 J) per 100cm2 skin area was used as a safety parameter to prevent treatment
complications. The optimal cumulative energy, which is proportional to the contour
deformity, was estimated based on the number of 10 × 10cm skin areas within the
treatment region. For example, a cumulative energy of 5 kJ would be delivered to a
patient with a small brachial region (10 × 10 cm), whereas 15 kJ would be delivered
to a patient with a large brachial region (10 × 30 cm), resulting in liquefaction of
adipose tissue and skin tightening (Fig.33.3).
In our sample, the patients were operated with a double diode HPL laser 924 and
975 nm, with high power and surgical laser. There were 552 female patients in 11
years, from June 2008 to June 2019. The mean age of patients is 53.4 years. 74.7%
33 Laser Lipolysis: Skin Tightening inLipoplasty Using HPL Dual Diode Laser
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Fig. 33.3 Sampling of 552 patients, women, treated with double-wavelength diode laser—924
and 975nm
are white and 54.7% married. In 154 patients, a laser with a wavelength of 924nm
was used to reduce sagging in the face.
Results
The distribution of the 552 patients who underwent laser lipolysis, according to the
different treated body regions, is shown in Fig.33.4. Laser lipolysis was mostly
performed on the ank region, followed by the facial or submental region. Parameters
such as cumulative energy, output power, and sequence of wavelengths used during
laser lipolysis in the different regions of the body are listed in Table33.1.
Measurements of the circumference of treated body regions taken preoperatively,
immediately after laser lipolysis, and 90 days postoperatively are shown in
Table33.2. The results showed a progressive tightening of the skin over time at all
treated sites.
Signicant differences in circumference values were observed in all patients
between preoperative and immediate postoperative measurements and between
measurements from postoperative day 90 and both the preoperative and immediate
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