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A. Perez
Fig. 14.15 Multiple patients from all walks of life and both genders showing their surgically well-dened and toned bodies
14 Hi-Def Liposuction- My Way
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References
1. Hoyos, A.E. (2007). VASER-Assisted High-Denition Liposculture
https://www.iscgmedia.com/. https://www.iscgmedia.com/
uploads/6/0/9/7/6097060/vaser_assisted_high_denition_liposuction.pdf
2. Varacallo M, Scharbach S, Al-Dhahir MA.Anatomy, Anterolateral
Abdominal Wall Muscles. [Updated 2020 Jul 31]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK470334/
3. Patronella CK.Redening abdominal anatomy: 10 key elements for
restoring form in abdominoplasty. Aesthet Surg J. 2015;35(8):972–
86. https://doi.org/10.1093/asj/sjv112.
4. Avelar J. Regional distribution and behavior of the subcutaneous
tissue concerning selection and indication for liposuction. Aesthetic
Surg J. 1989;13:155–65.
5. Gasparotti M, Lewis CM.Supercial liposculpture: manual of technique. NewYork, N.Y: Springer-Verlag; 1990.
6. Gasparotti M.Supercial liposuction: a new application of the technique for aged and accid skin. Aesth Plast Surg. 1992;16:141–5.
7. Matarasso A, Swift Richard W, Rankin M.Abdominoplasty and
Abdominal Contour Surgery: A National Plastic Surgery Survey.
Plast Reconstr Surg. 2006;117(6):1797–808.
8. Gasperoni C.Suction-assisted Lipectomy of the subdermal liposuction fat layer: subdermal liposuction. Annals of the International
Symposium. Recent Adv Plastic Surg. 1990;90:477.
9. Gasperoni C. Subdermal liposuction. Aesth Plast Surg.
1990;14:137–42.
10. de Souza Pinto EB, Indaburo PE, Da Costa MA, Martinez YP,
Gerent KMM, Iwamoto H, Marão Miziara AC.Supercial liposuction: body contouring. Clin Plast Surg. 1996;23(4):529–48.
11. Klein JA. Post-tumescent liposuction care: open drainage and
bimodal compression. Dermatol Clin. 1999;17(4):881–9.
12. Schlesinger SL, Kazcynski AJ.Use of Reston foam in liposuction.
Aesthet Plast Surg. 1993;17(1):49–51.
13. Newall G, Ruiz-Razura A, Mentz HA, Patronella CK, Ibarra FR,
Zarak A.A retrospective study on the use of low-molecular-weight
heparin for thromboembolism prophylaxis in large volume liposuction and body contouring procedures. Aesthetic Plast Surg.
2006;30(1):86–95.
Part IV
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Use of Technology for Lipo-contouring
Ultrasound Assisted Liposuction
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JavierPalacios
15
15.1 Introduction
Liposuction techniques have improved through the experience of the most experienced surgeons, wanting to achieve
before, decrease the volume of fatty tissue in a given area,
subsequently, shaping some areas to achieve better contours
as a sign of beauty, enhance the beauty of the aesthetic contour appropriate to trends and fashions such as thinning of
the crotch, lower waist circumference or arms with very
diminished views and currently marked imitable musculature to give the patient the sporting effect. Liposuction
assisted by (homogenized ultrasonic emulsier) ultrasound
has managed to incorporate a method for using thinner cannulas, less trauma to tissue other than fatty tissue, and more
renement by shortening the space between the dermis and
subdermal tissue by further decreasing the amount of adipose tissue without injure the subdermal plexuses reaching
contours or sculptures not previously attainable in human
models [1–4].
The ultrasonic emulsier homogenizer is a device
designed to emulsify by means of ultrasonic vibration;
reducing the size of the particles to distribute them evenly
and thus perform the effects of homogenization, dispersion,
and emulsion.
The system vibrates at 39kHz (39,000 pulse per second),
converting electrical energy to mechanical ultrasound waves
thanks to sonotrodes.
areas where liposuction was previously done, bleeding,
bruises, dermal lesions, among others.
In the liposuction of the upper limb, it confers an important security in the treatment of the circumference of the arm
with great ease of elimination of adipose tissue being
squeezed and not aspirated, likewise, after a traditional liposuction, the ultrasonic probe can regularize the tissue allowing greater retraction and avoiding irregularities that are
perceived to muscle tension (Fig.15.1).
In jowl liposuction and in the arms, it is possible to treat
only with the ultrasonic device without performing subsequent liposuction by performing a manual scan for the
removal of emulsied tissue (Fig.15.2).
The face is a eld where the ultrasonic probe is of great
importance since it can be maintained in the subcutaneous
space with a thinner cannula, performing an ultrasound stimulation, emulsifying the tissue to be treated and obtaining
15.2 Material andMethods
The techniques achieved by traditional liposuction may be
adapted to the use of an ultrasonic device, denoting greater
safety and less likelihood in visible irregularities, the appearance of postoperative brosis, the surgeon’s effort to treat
J. Palacios (*)
Cosmetic Plastic Surgery, Veracruz, Mexico
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_15
Fig. 15.1 Use of ultrasound allows greater retraction as well as avoids
irregularities
251
252
LAUH lipo, abominoplasty with breast augmentation A) PreOp. and
B) 20 days Post OP.
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J. Palacios
a
b
Fig. 15.2 (a, b) Use of plain ultrasound without subsequent
Liposuction helps in retraction of the tissue along with Lipolysis as
seen on the jowls as well as the arms
better retraction, helping to tunnel and dissect ultrasonically
the skin prior to surgery of rhytidoplasties or advances of
tissues and aps.
The upper abdomen can only be treated with emulsication in conventional tummy tuck, reducing the restricted
areas for liposuction, and allowing the contour to be improved
without compromising the vascular supply (Fig.15.3).
In the case of metabolic diseases, it has a great impact on
the removal of the excess fatty tissue with the need to concentrate the energy in the areas that contain the large fat
stores using great power and later the fat can be extracted by
traditional liposuction (Fig.15.4).
Advantages with ultrasound-assisted liposuction
• Less edema at initial trauma.
• Less injury to structures other than fatty tissue.
• Better and faster recovery.
• Less pain and edema during recovery.
• Virtually no bruising.
• Less exhaustive to the surgeon.
• Preservation of the supercial vascular plexus.
• During the time of use of the ultrasonic technology it
allows greater time to the infused solutions to generate the
major effects of vasoconstriction and tumescence.
a
Fig. 15.3 Lipocontouring of the upper abdomen was undertaken in association with abdominoplasty and breast augmentation in Case 1 whereas
liposuction, abdominoplasty, and fat grafting to buttocks were done in patient 2
b
a
LAUH lipo, abominoplasty A) PreOp. and B) 30 days Post OP.
b
15 Ultrasound Assisted Liposuction
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Fig. 15.4 Excess fatty tissue
removed from above and
outer side of the buttocks with
adequate skin retraction
253
15.3 Patient Selection
Liposuction was performed as a primary procedure to improve
body contouring, to tighten relaxed skin and supporting structures. The candidate for a lipoaspiration is the relatively normal-weight individual who has excess fat in certain areas of
the body. The procedures were performed under general anesthesia or by regional blocks and sedation depending on the
region to be treated and the patient’s preference.
15.4 Technique
Considerations for its use.
• Use 1: 1 or 2: 1 tumescent inltration technique.
• Time taken for use of technology is based on the amount
of tissue, the perception by the surgeon’s hand, and the
treated area.
• Movements of the probe should be “way slower” than
during liposuction. It should be a continuous movement,
never be static.
• Progression should be from deep planes toward the
surface.
• Each area is to be treated in an anatomical fashion.
• Never stop feeling the tip of the ultrasonic cannula.
It is a more gentle technique with the manipulation of the
tissues and that allows to extract the fat in a more atraumatic
manner, this is without passing the cannula so many times,
without producing much bleeding, inammation, and
bruising.
The technique comprises three phases:
1. Inltration: A tumescent solution is injected into the fat
deposit areas before suctioning the fat. The inltration
liquid is a mixture of saline, lidocaine, and epinephrine.
The uid helps to eliminate fat easily, helps reduce blood
loss, and provides anesthesia before and after surgery,
and also helps reduce bruising.
2. Emulsication: Ultrasound energy that is concentrated at
the tip is now used in the subcutaneous tissue starting
from the deep fat and gradually moving toward the supercial fat. The ultrasonic vibration of the probe causes
rupture of the lipocytes and the heat generated by the
ultrasound energy promotes the production of collagen
that increases the elasticity of the skin. This is one of the
reasons why emulsication can be used in middle-aged
people since the chances that the skin has a greater chance
of recovery are good, as well as that the skin has a better
appearance after surgery.
3. Evacuation and contouring: By moving the cannula in
and out repeatedly, the fat is released and then aspirated.
Although the lipoaspiration is performed in two planes,
the greatest intensity of the lipoaspiration is done in the
deep plane with a cannula of 4mm and in the supercial
SMAS plane with a cannula of 3mm, for better contouring of the skin (Figs.15.5 and 15.6).
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Fig. 15.5 Shrinkage of the
facial skin visible after dual
plane emulsication and
suction in the face and neck
Fig. 15.6 Ultrasonic
homogenizer has been used to
shape this body and create the
muscle prominences as well
as the denition of the waist.
The aspirated fat has been
collected in a sterile container,
which can be seen to have less
blood as compared to
traditional liposuction. Fat
from the aspirate if collected
sterile can be safely used to
augment other body parts
J. Palacios
15.5 Complications
Its drawbacks include the possibility that it can cause thermal burns, is slower than conventional liposuction, requiring
a longer surgical time, and above all that the effects of the
energy generated by ultrasound are not limited only to fat,
the role they play may cause demyelination of peripheral
nerves.
The ultrasound-assisted liposuction technique requires
inltrating the adipose tissue with a large amount of tumescent uid in order to dissipate the powerful ultrasonic effect
and achieve the cavitation effect for emulsication of the
adipose tissue, which is why it is important that the constant
and correct measurement of inltrated volumes, temperature, oximetry, and urinary output are required.
The technique of ultrasound-assisted liposuction has
many advantages over many of the other technologies that
assist in liposuction; however, the use of an instrument with
a great capacity for cavitation and dissection should be used
by a surgeon who is skilled in the art of liposuction because
its penetrative capacity can ease penetration of abdominal
spaces, its ultrasonic vibrational power increases heat so that
lack of movement can cause the harmful thermal effect to the
subdermal and dermal tissue. Most of the expected complications should be identied separately, taking those that are
due to the technique of extraction or liposuction and that due
to the use of the ultrasonic instrument.
Irregularities, lesions of supercial vascular plexuses,
bruises, and loss of continuity of the skin, can be classied as
complications due to the aspiration cannula being very
supercial from its placement according to the depth, as well
as the placement of the liposuction cannula suction holes
toward the subdermal part in an already injured tissue. The
presence of seromas, burns, hydroelectrolyte imbalances, or
metabolic disorders due to infused volume considerations
may be due to excessive use of the ultrasonic instrument, the
15 Ultrasound Assisted Liposuction
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255
immobility of the cannula depending on the function, and
poor management technique of the tip of the ultrasonic emitter. The complex metabolic disorders that derive from volume management will have to be constantly assessed and
treated during and after surgery, taking into account that the
inltrated volume may third space during ultrasonic emulsication. Emulsied aspirate will contain less uid than in the
traditional technique, hence the consideration to use this
technique under the regional anesthetic block.
It is common to think of the presence of seroma in the
patient in ultrasound-assisted liposuction due to the emulsication that has been performed, so the ports must be kept
open or placement of drains should be considered that allow
uid exit. Compression garments for the postoperative period
should be worn 24hours with a single removal for important
physiological needs, while maintaining the compression of
the treated tissues thus avoiding the collection of liquid in
uncompressed spaces.
Burns, loss of continuity of the skin or infections if present, should be treated by the surgeon with the expertise and
individualizing the treatment according to its extent, the
severity of burns, or the pathogen.
15.6 Conclusion
Ultrasonic emulsifying liposculpture has enabled the surgeon to incorporate a method to use thinner cannulas, causing less trauma to tissue other than fatty tissue, more
renement by reducing the volume of the subdermal tissue.
* The authors have not received any nancial compensation or have interests in the company Indemex SA de CV., Or
with the emulsier ultrasonic homogenizer.
References
1. Avelar J.Regional distribution and behavior of the subcutaneous
tissue concerning selection and Indi- cation for liposuction. Aesthet
Surg J. 1989;13:155–65.
2. Zocchi ML. Ultrasound-assisted lipoplasty. Technical renements
and clinical evaluations. Clin Plast Surg. 1996;23:575–98.
3. Gilliland MD, Lyos AT.CAST liposuction of the arm improves aes-
thetic results. Aesthet Plast Surg. 1997;21(4):225–9.
4. Rochrich RJ, Beran SJ, Di Spaltro F, etal. Extending the role of
liposuction in body contouring with ultrasound assisted liposuction.
Plast Reconstr Surg. 1998;101:1090–102.
Radio Frequency Assisted Liposuction
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MohanThomas andJamesD’silva
16
Radio frequency-assisted liposuction (RFAL) is a novel
technique of energy-assisted liposuction in which RF
energy is used to break down and liquefy the fat deposits
resulting in easy evacuation of fat as well as stimulate collagen formation and contraction via thermal effects of radio
frequency. BodyTite® (Invasix, Yokneam, Israel) was rst
introduced in 2009 for body contouring and skin tightening
[1]. It is an RFAL device that has shown the capability for
signicant contraction through a minimally invasive procedure. Skin tightening by RFAL is due to its effect on collagen in the dermal and subdermal bro-septal network
(FSN) tissues.
The following changes induced by RF have been utilized
in medicine [2]:
1. Ablation of tissue: Focused high-intensity RF on a monopolar tip is used for cutting or removing tissue through
thermal evaporation of tissue. There is minimal heatinduced damage to the surrounding tissue which happens
due to the conversion of tissue from solid to vapor caused
by the use of the highly dense focused energy.
2. Coagulation: This is undertaken using a broad tip that dissipates the energy causing coagulation of blood vessels
and provides hemostasis during surgery. This process can
also be undertaken on soft tissue which causes necrosis of
the tissue. Coagulation is especially preferred when excision of the tissue is not required or not practical.
3. Collagen contraction: The tertiary structure of the collagen molecule (protein) is modied due to transformation
caused by the application of higher temperatures.
Predictable collagen contraction happens when the temperature of the tissue is increased in the range of 60–80°
which can cause skin necrosis. Hence usually multiple
sessions and a longer time are required to achieve good
results.
4. Tissue hyperthermia: This is a popular skin treatment
method in which a natural physiologic process is stimulated when the treated tissue is heated to superphysiologic
temperatures. This tissue heating to subnecrotic levels
does not cause coagulation but stimulates broblasts
which in turn synthesizes collagen and may alter the
metabolism of adipocytes to cause lipolysis of the fat
cells.
16.1 RFAL Device
The radio frequency device consists of a platform (Fig.16.1)
which generates the energy which is transmitted to the handpiece. It has a number of attachments, which include an
external bipolar handpiece, microneedling handpiece as well
as an internal probe hand-piece (bipolar), which is specically used for tissue contraction during liposuction. The
external probe which is wider stays in touch with the external
skin while the internal probe is passed through a small incision into the subcutaneous adipose layer thus treating the
intervening soft tissue between the two probes by radio frequency. The internal probe may be hollow which can be connected to the liposuction machine so that simultaneous
liposuction as well as RF treatment can be carried out.
Blugerman etal. showed the soft tissue linear contraction,
described as the “bro-septal network” response to RF
energy to be as high as 47% with thickening of the collagen
matrix on histological examination of skin biopsies [3].
M. Thomas (*) · J. D’silva
Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil
University, Mumbai, Maharashtra, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_16
257
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M. Thomas and J. D’silva
16.2 HandPiece
The RF energy is generated in the Generator platform of the
BodyTite machine and transmitted through the handpiece
between the internal electrode in the subcutaneous tissue and
the external electrode on the skin (Fig.16.2). The RF energy
passes from the internal electrode and is captured by the
external electrode through the skin layers and the density is
higher around the smaller internal electrode as compared to
the larger external (Fig. 16.3a). This causes signicantly
higher deeper tissue temperatures as compared to the skin
surface only in the tissues between the electrodes as seen in
Fig.16.3b.
Fig. 16.1 The platform of radio frequency device Bodytite
Fig. 16.2 Handpiece being
shown with the internal probe
in the subcutaneous tissue
®
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