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27 Liposuction 360°
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27.5.1.2 Ultrasound-Assisted
Liposuction (UAL)
Described by Zocchi, this form of liposculpture
uses ultrasound energy to generate mechanical
lipolysis and facilitate subsequent fat extraction. It is based on conversion of electrical
energy into 16 kHz ultrasound waves, which
ultimately create a molecular destabilization of
tissues, and eventually their cavitation and cell
fragmentation.
Therefore, it is a technique that requires two
surgical phases. Initially, applied ultrasounds
favor fat cell fragmentation, and then by means
of suction-assisted liposuction, extraction of fatty
tissue is carried out.
UAL’s characteristics and way of functioning
is what denes its advantages. By performing a
relatively atraumatic adipocyte disruption, its use
in more brotic areas, secondary liposuctions or
HIV-associated lipodystrophies obtains better
results and facilitates the process. Surgical bleeding is reduced considerably, being able to perform higher volumen extractions in one surgery
without needing to autotransfusion or controlled
hypovolemia methods. Less operative bleeding
causes a reduction of hematomas and peri- and
post-surgical ecchymoses, achieving greater
patient comfort during the following weeks.
Finally, many authors claim that extracted tissue
is of better quality in case fat grafting is to be
performed during the same procedure, due to
cavitation and its protective effects on fat cells.
Third generation UAL device, known as
®
VASER
(Fig.27.6), allows for greater fragmentation of fatty tissue at minimum temperatures,
which reduces the risk of thermal damage associated with previous generation devices.
Despite many defenders, UAL market is not
extense. Its high cost and longer learning curve,
as well as risk of thermal damage made many
surgeons opt for other technologies with faster
learning curves [10].
27.5.1.3 Power-Assisted Liposuction
(PAL)
This system is based on the use of cannulas connected to an engine that generates high-speed
movement, either oscillating or reciprocating.
451
Fig. 27.6 VASER machine, third-generation UAL
The rst PAL device, FDA approved, was
MicroAire Surgical Instruments in 1998
(Fig.27.7), with a cannula that vibrates reciprocally between 2000 and 4000 rpm and a 2 mm
excursion.
With these characteristics, the constant movement of the cannula tip facilitates its penetration
through tissues, making its use in brotic tissues,
HIV lipodystrophy and secondary liposuctions of
great help, hence considered by many surgeons
the ideal liposuction system. In addition, in primary liposuction surgery, PAL allows optimizing
the process, reducing surgical time, blood loss
and permits larger volume extraction with less
effort.
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Fig. 27.7 MicroAire surgical instruments with its reciprocating cannula
The problem of rst-generation PAL systems
has been mainly associated with excessive vibration in the cannula handle, which is transmitted
to the surgeon’s hand creating a sense of discomfort. Therefore, new generation devices reduced
associated vibrations and noise generated. As no
heat is produced, thermal damage is not
possible.
Among the disadvantages of PAL is its high
price, since MicroAire device or similar is necessary, as well as specic cannulas and mounting systems. Learning curve, as with UAL,
remains longer than with SAL. Despite all
drawbacks, many surgeons consider that advantages of PAL far outweigh its disadvantages,
making it one of the best selling systems in the
market nowadays [11].
I. Fakih-Gomez et al.
27.5.1.4 Laser-Assisted Liposuction
(LAL)
Application of laser in plastic surgery has
increased exponentially in recent decades, from
its use in facial resurfacing to the elimination of
tattoos and vascular lesions. Apfelberg and his
team in California incorporated, in 1994, the neodymiun-doped, yttrium aluminum garnet (nd:
YAG) laser to a liposuction cannula. With a frequency of 1064 nm, the main chromophore of
nd:YAG is water. Despite promising results, this
system was not approved by the FDA, so research
focused on nding a new system that provided
three additional benets to liposuction: reduction
of operative bleeding, acceleration of postsurgical recovery and favoring as much cutaneous retraction as possible. The best-known
system up to date is SmartLipo® (Fig. 27.8),
which uses photothermolysis, acting selectively
on the desired tissue (desired chromophore)
Fig. 27.8 SmartLipo device, the best-known system of
LAL
without affecting the surrounding ones. There are
several lasers available nowadays, with nd:YAG
and diode laser being the most studied and performed. Different wavelengths can be used
depending on the desired target, including collagen, fat, water, or hemoglobin. Lasers range
between 800 and 1400nm, with the lowest wavelength being more selective for hemoglobin and
blood vessels and the highest for water (acting
primarily on collagen and fat), generating greater
cutaneous retraction.
Therefore, LAL systems allow selective lysis
of adipocytes, reducing total fat volume; selective
coagulation of blood vessels, reducing peri and
postoperative bleeding thus minimizing appearance of ecchymosis in subsequent weeks; and
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selective thermal damage on dermal collagen, initiating cellular repair process with increased
broblasts and collagen generation, and ultimately consequent cutaneous retraction. Despite
these promising ideals, comparative studies of
LAL with SAL have not found statistically signicant improvements between both techniques.
The main disadvantages of LAL lie in the possibility of thermal damage, longer learning curve,
as well as cost of the equipment [12].
27.5.1.5 Water-Assisted Liposuction
(WAL)
Using a cannula with a fan form triangular tip,
water is injected under pressure in a pulsatile
manner for inltration of a tumescent solution.
WAL system, known as BodyJet® (Fig. 27.9),
performs atraumatic and blunt hydrodissection
of fatty tissue, as well as expansion of intercellular space, favoring its posterior extraction. The
ow and pressure are controlled by the surgeon
and adjustable during the procedure. There are
many similarities between the concept of WAL
and UAL.Both aim to dissect tissue and generate lipolysis, which then facilitates lipoaspiration by suction. However, in the case of WAL,
there is no heat production, so thermal damage
to the dermis is not a concern. On the other hand,
it does not generate additional retraction, present
with UAL [13].
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27.5.1.6 Radiofrequency-Assisted
Liposuction (RFAL)
BodyTite® (Fig.27.10) is a bipolar device, based
on the application of a radiofrequency current
generating lipolysis and dissolution of fat cells,
producing tunnels when fat dissolves, along with
thermal effect on the skin for cutaneous retraction later. On the other hand, an aspiration cannula that removes coagulated and dissolved fat is
incorporated in the same device. BodyTite is
composed of a hollow Mercedes-tip cannula and
is silicone coated, except for the tip where aspiration takes place and is one of the system poles.
Another circular electrode is located in the outer
Fig. 27.9 Bodyjet a device using WAL
Fig. 27.10 BodyTite bipolar radiofrequency applicator
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skin area. Radiofrequency current ows between
the two poles, generating skin retraction due to
thermal damage through all skin layers and lipolysis at the tip of the cannula. Dissolved fat is
aspirated at the moment through the holes provided by the cannula tip. This device incorporates
a real-time measurement of skin temperature in
the external zone, which allows for a uniform
application, improving patient safety and reducing risk of burns. The system is equipped with
internal and external temperature sensors so that
the operator is alerted when to proceed and when
to stop avoiding heat damage. After BodyTite,
approximately 30% of the fat is extracted but
must be supplemented with SAL or PAL to nalize liposuction.
Renuvion J Plasma
®
(Fig. 27.11) uses both
helium and RF energy to heat tissue. By adding
energy to helium gas, the device creates plasma,
which contours to the application area and evenly
delivers the energy. RF waveform then ows
through this conductive plasma to create additional benecial heating of tissue. As the tip of
the device is drawn across an application area,
the energy is applied uniformly along the overlying dermis, septa, and muscle fascia. This allows
for a full coagulative treatment (Fig.27.12), customized in real time to the unique contours of the
subcuticular space. With Renuvion, less than
0.1% of helium gas is converted into plasma, so
most will remain in its gaseous state. As helium is
more thermally conductive than air, the unconverted gas ows across tissue, drawing away
excess heat like a subdermal air conditioner, minimizing any unintended thermal effect.
I. Fakih-Gomez et al.
Fig. 27.12 Coagulative treatment of Renuvion J Plasma
on the retaining connective network ligaments to produce
cutaneous retraction
The main advantage of RFAL compared to
previous systems is the degree of cutaneous
retraction produced, achieving optimal results
with this process. Detractors of this type of technology argue that thermal damage to tissues is
one of its main disadvantages, but in review studies performed, there is no clear evidence of higher
incidence of skin damage [14] (Table27.1).
27.5.2 Patient Positioning
After preoperative markings, the patient lies over
an auxiliary bed in a supine position. Normally,
we use general anesthesia for large volumen liposuction and sedation in case less volume is to be
aspirated.
After intubation, the patient is rolled to prone
position over the operating table (Video 27.2).
Skin of the posterior trunk is prepared with betadine, and drapes are placed (Fig.27.13). A pillow
is placed under the hip and knees are protected
with a cushion (Fig.27.14).
Fig. 27.11 Renuvion device
27.5.3 Procedure Step by Step
Incisions are made and access ports are placed to
protect the skin, which are secured with 2/0 silk
suture (Video 27.3). We use home-made ports
with a 2cc syringe as shown in Video 27.4. Then
we start inltration of Klein solution from 1 to 2
access points (one in the intergluteal crease and
the other, if needed, in the back’s midline at T11–
T12 vertebra level) in a fanning out manner
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455
Table 27.1
Fat emulsication
Skin retraction
Temperature control
Comfort
Marketing
Cost +++
Time
+: most advantageous, −: less advantageous
Comparison of different types of liposuction methods used nowadays
SAL UAL PA L LAL WA L RFAL
−
−
− − −
−
−
− −
+++ ++ ++ ++ +++
+
+++ + +++ ++ +++
+++ + +++ +++ +++
−
−
+ + +
+++
+++
++
− − −
−
−
+++
+++
−
Fig. 27.13 Skin preparation with betadine and placement of drapes
(Fig.27.15). We always perform SAFE liposuction (separation, aspiration, fat equalization)
[15]. The key concept of 360° liposuction is the
treatment of “bra roll.” In the back, at the midlevel area, there exists a zone of brous adhesions normally accentuated by the constant use of
bras upon many years. This causes the effect of
hanging fat we previously described. It is
extremely important to treat this area intensively
during liposuction of the back, both to weaken
the inserts and to shape the costal area, and make
a beautiful transition to the concavity of the waist
[16]. If strong adhesion or excess skin is present,
open surgery is mandatory (Fig.27.16).
Surgeon’s sensations in the liposuction technique will also be different. A much more com-
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Fig. 27.14 A pillow is placed under the hip to facilitate
liposuction and lower abdominal pressure
I. Fakih-Gomez et al.
Fig. 27.15 From 2 access points and in a fanning out
manner, we can inltrate and aspirate the full back
pact fat with denser subcutaneous tissue and
thicker dermis constitutes this area, all of which
will make use of more aggressive cannulas useful
Fig. 27.16 Strong adhesions (marked with an asterisk)
which cause bra rolls (b) to hang over
and safe. However, always take precaution of not
perforating the rib cage, and thus a possible thoracic damage. (Fig.27.17).
27.5.4 Surgical Modications
As for the lower area, preparatory analysis and
identication of the gluteus silhouette, the sacrum
triangle and depressions of the posterior iliac
spine, known as Venus dimples, is essential.
Liposuction should always be done above the
upper gluteal fold, creating a difference in subcutaneous tissues thickness that visually enhances the
buttock area and improves the rounded contour.
Sacral and lower back area is usually very grateful,
as skin retraction is powerful, paying special attention to Venus Dimples, which provide a much
desired and youthful aesthetic improvement.
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457
Fig. 27.18 Incisions with ports placed on the anterior
trunk
27.5.5 Technical Tips toImprove
Outcomes andAvoid
Complications
Fig. 27.17 We usually treat bra rolls and break adhesions
with a basket cannula, a very safe instrument in the back
due to thick dermis
Approaching the anks from the prone position also brings great aesthetic improvement to
body contouring surgery by generating new dissection tunnels, removing more fat, and leaving
this area almost completely “fat-empty.” Once
the posterior part is done, patient is ipped to a
supine position, the anterior trunk skin is prepared with betadine and new drapes are placed
(Video 27.5). Inltration and liposuction of the
anterior part are usually done through 5 incisión
ports (2 at the pubis in line with each lateral border of rectus abdominis, 1 at the supraumbilical
area, and 2 at the inframammary fold (Fig.27.18).
Liposuction is done to all the anterior part making special attention to linea alba and linea
semilunaris. To mark all lines, we perform dermal carving with a basket cannula. It is essential
to remove more fat with a tonal progressión so
that the lines are marked with a natural appearance [17].
Warning The ideal glass-hour shape will be
c
considerably improved when treating the
flanks aggressively.
27.6 Postoperative Care
After surgery, a compression garment for the
liposuction area is placed, which will be maintained for 4weeks. Usually we use panty type
prefabricated garments that cover thighs and
abdomen (Fig.27.19). Also, white foam may be
added under the garment to generate a more
even compressión and therefore better skin
retraction. Also it avoids surface irregularities
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I. Fakih-Gomez et al.
maneuvers, nausea, and vomiting will rise
blood pressure therefore increasing bruising
in the postoperative period.
In our case, analgesia consists of intravenous
infusión pump with paracetamol, dexketoprofen
+/− a mild opioid. We usually add ondansetron,
metoclopramide, tranexamic acid, and captopril
during the rst 24 h to prevent nausea and
unwanted blood pressure spikes.
The patient is encouraged to stand up and
deambulate as early as possible. In our experience, walking the same afternoon of surgery has
led to an early recovery and fewer complications. By not carrying a bladder catheter, the
patient feels free to walk which favors early
deambulation; most of the times, even to go to
the toilet.
A blood sample is taken to measure hematocrit. If no setbacks are present, and the patient’s
general condition is good, they can be discharged
with ofce revision 4days later.
Fig. 27.19 Compression garment goes from the knees
till the inframammary fold
due to improper use or ill-tting compression
garment [18].
Bladder is emptied at the end of the surgery
and the patient leaves the operating room without
catheterization.
It is essential to maintain close control of
blood pressure, trying not to exceed 120mmHg
of systolic blood pressure. To achieve this goal,
good pain control in the rst postoperative hours
is imperative, so as to avoid bleeding and uid
accumulation.
Warning Controlled perioperative manage-
c
ment of blood pressure is imperative. Valsalva
Warning Sun exposure should be
c
discouraged during the first month to avoid
pigmentation of subcutaneos hematomas
that appear after liposuction. Sun cream SPF
50+ is recommended during summer, as
clothes do not prevent some penetration of
UVA radiation.
27.7 Outcomes andPrognosis
After 30 to 40days, inammation has decreased
considerably. The provisional result is getting
closer to the nal result, which can be assessed
3months after surgery (Figs. 27.20, 27.21, and
27.22). In this type of procedures, external radio-
frequency, and ultrasound machines are important to deal with extensive internal trauma and
inammation, as well as favoring reduction of
postliposuction brosis (Fig. 27.23). In years
prior to usage of these devices, results obtained
were not entirely satisfactory for surgeons,
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459
Fig. 27.20 Preoperative and 1year postoperative photo
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Fig. 27.20 (continued)
I. Fakih-Gomez et al.
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