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a
Fig. 16.3 (a) Shows the higher density of RF waves in the internal electrode which signicantly increases the subcutaneous temperature as seen
in (b)
16.3 Indications forUse ofRFAL
b
3. RFAL is also effective for localized skin laxicity which
cannot be addressed by skin excision as it may leave very
1. Patients having moderate fat deposits in the abdomen
with average skin tone will likely leave a poor aesthetic
result with liposuction alone due to inadequate skin contraction but at the same time is not severe enough to warrant skin excision (Fig.16.4a and b).
2. Areas of body such as the submental area, medial thighs,
arms and abdomen in which the ‘Zones of Adherence’ are
not prominent are a good indication for radiofrequencyassisted liposuction (RFAL) for satisfactory contouring
who otherwise would have undergone only traditional liposuction with concerns of post-operative skin laxity. The
increased margin of safety achieved with a very effective
RFAL technology, causes signicantly more skin contraction during healing as compared to traditional suction-
prominent scars. Eg. In the peri-umbilical area (Fig.16.6)
or in the arms when patient has undergone massive
weighty loss. In such cases it is important that liposuction
is not undertaken.
4. RFAL technology is showing tremendous promise in
the management of cellulite, which is a big concern
for many middle-aged ladies. This is due to the reorganization of the collagen fibers and formation of
bands at the dermal- hypodermal junction and preventing fat herniation from the subcutaneous layer into the
deep dermis, which is manifested as cellulite. The
elimination of subcutaneous fat and the modulation of
tissue fibers further contribute to cellulite improvement [4].
assisted lipectomy (SAL) alone (Fig.16.5a and b).
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M. Thomas and J. D’silva
a
Fig. 16.4 (a, b) Showing the fat deposits as well as skin laxity in the lower abdomen and inner thighs
b
a
b
Fig. 16.5 (a) Showing the lax arm skin associated with fat deposits.
(b) showing the fat deposits in the submental area with skin laxity
Fig. 16.6 Skin laxity in the peri-umbilical area with minimal infraumbilical laxity
16.4 Contraindications
Patients with active infections.
Recent Isotretinoin use.
Patients with pacemakers.
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16.5 Benets ofRFAL [1]
1. Speed of treatment: RFAL handpieces are usually hollow
except for the ones which are to be used on the face. This
helps in undertaking simultaneous fat aspiration along
with the use of radio frequency technology, which will
make the treatment speed comparable with that of
PAL. This high speed of treatment is achieved because
the power applied is efciently utilized and prevented
from scattering by keeping it focused on the treatment
zone between the internal and the external electrode.
Analysis of the ratio of the energy applied to the volume
of fat tissue treated showed that to reach a clinically therapeutic thermal effect in a standard size lipoplasty zone,
the energy of approximately 50J/cm3 is required. So if
RF power of 40–50W is used, then the speed of volumetric treatment will be in the range of 1–1.2s/cm3.
2. Ease of use: The device is very safe due to the temperature sensor in the external electrode, anticarbonization
protection of the internal electrode, and various depth
control options.
3. Uniformity of temperature increase: Thermal injury to
the skin is prevented by a closed-loop temperature control
system along with impedance control and automatic cutoff of the power when the critical temperature is reached.
This helps in undertaking treatment for longer periods at
the critical temperature so that all the soft tissue in the
treatment zone reaches a constant temperature
distribution.
4. Fat necrosis: Extensive destruction of adipocytes is seen
due to coagulation of the adipose tissue, which is visible
clinically as well as on histology specimens taken from
the treated area. Figure16.7 is taken from the study done
by Paul etal. and published in the Aesth Plast Surg (2011)
35:87–95. https://doi.org/10.1007/s00266-010-9564-0.
5. Collagen remodeling and skin contraction: RFAL thermal
stimulation causes very powerful contraction and thus
retraction of the brous and dermal matrix present in the
entire subcutaneous tissue in the treatment area.
Coagulation of the reticular and deep dermal collagen
causes a signicant change in the connective tissue
structure.
Fig. 16.7 Adipose-septal tissue contraction during RF energy delivery at different time points performed on a tissue excised after abdominoplasty [5]
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16.6 Principles ofRadio Frequency
Assisted Liposuction (RFAL)
It is usually recommended that high-energy RF is directly
applied to the subcutaneous layer without prior liposuction
or along with liposuction; however, we recommend rst nishing moderate liposuction and then using the RF energy,
which we call the two-step method, for three reasons:
1. The two-step method can initially create working chan-
nels by liposuction, which enables RF to be applied more
easily and accurately.
2. Moderate liposuction can expose the subdermal FSN tis-
sue (bro septal network), allowing the RF energy to
directly affect the collagen of the FSN and increasing the
extent of contraction. Fewer complications occur as a
result of applying less energy after rst removing fat
tissue.
3. It is very difcult for the surgeon to monitor the lipocon-
touring of a particular area as well as the change in temperature for tissue remodeling. There may be a
compromise with tissue tightening or formation of defects
due to overaggressive liposuction.
M. Thomas and J. D’silva
16.7 RFAL Procedure
1. Choose the right RFAL probe:
Choosing the correct probe for the area of treatment is
of paramount importance since it depends on the length
and diameter of the internal probe. Larger probes have to
be chosen for large areas of fat deposits such as thighs
and abdomen so that adequate evacuation of fat as well as
application of higher energy is possible. Face and neck
skin tightening should be undertaken with a non-hollow
cannula. Handpieces with varying length of the internal
probe are available. Figure 16.8 shows the cannula of
various sizes.
2. Positioning the patient:
Placing the patient in the supine position is best for the
abdomen, inner thighs, and arms as easy access is possible due to limb mobilization.
3. Access points:
Multiple access points are required since the probes
being straight cannot traverse the curves. Also being delicate (hollow) they can be broken when traversing through
curved areas.
4. Super-wet tumescent uid inltration:
We follow the super-wet tumescent uid inltration
according to the Klein technique [6]. A 1:1 infusion of
tumescent uid is carried out in the area where radio frequency assisted tightening is required. It is preferable to
Fig. 16.8 Various types of handpieces varying from 4mm diameter to
2mm diameter with no associated suction for the neck
wait a good 15 mins to allow the alpha-adrenergic receptors to be activated by the adrenaline and thus achieve
hemostasis during liposuction.
5. We rst undertake a thorough debulking liposuction of
the area to be tightened using either traditional suctionassisted liposuction with a Mercedes cannula or utilize
the liposuction aspect of the RFAL cannula without initiating the radio frequency energy for skin tightening. The
overall pinch test of the areas is reduced by the evacuation of the fat in the deep layers. Arms and thighs have a
single layer of fat hence it is imperative that care is taken
when debulking fat. A few precautions namely, taking out
fat from the deeper layers, do not suck outside the marked
area, assess skin thickness by utilizing the pinch test frequently should be taken.
6. Once adequate fat removal has been done and/or skin
excision undertaken and partial skin closure completed,
sterile ultrasound gel is applied on the area requiring
radio frequency as seen in Fig.16.9.
7. The radio frequency hand set is not yet connected to the
body of the Bodytite machine. The settings used include
energy as 30–40W for arms, and 55–65W for abdomen,
hips and anks.
Adjustment control for
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The usual cutoff temperature settings used are
38 °C–42 °C, which should be maintained for at least
2 mins once the desired thermal effect was reached.
Treatment areas are divided into ~12×12 cm thermal
zones so as to target small and specic areas for the best
result and the mean effective energy delivered to each
treated zone may remain approximately ~10 kJ
(Fig.16.10).
The RF energy applied to the patients’ adipose tissue and
skin is concentrated between the two electrodes (internal as
well as external) and is utilized maximally for adipose coagulation and skin contraction without the risk of heating structures deeper into the probe. The maximum temperature
achieved is at the internal probe, which is about 20° higher
than that measured supercially by the external probe.
8. Adjustment can be undertaken to control the width or the
distance between external and internal electrodes
(Fig. 16.11), which should be kept in the range of
5mm–50mm based on the thickness of the tissue thus
allowing for uniformity in treatment at the targeted treat-
ment depth. The contact is maintained between the
external electrode and the skin by a spring-loaded pivot,
which requires sufcient gel medium for transmission of
the waves
9. Depending on the tissue thickness and the curvature of
the treated area energy of upto 75W of RF power can be
applied. Inbuilt technology helps in measuring the amount
of energy utilized during the treatment session in real
time as well as measures the external and internal temperatures in the tissue at the point of contact with the
probes as well as the tissue impedance.
The device is slowly moved in the area where skin tightening is required (Fig.16.12a–c) taking care that the probes
do not stay in one place for a long time as in a liposuction
technique. Ideally, the full length of the cannula should be
used and there should be no uncoupling.
10. Medium and large volume fat deposits need aspiration of
the melted fat whereas small of fat deposit such as the
neck and face will not need aspiration as the liqueed fat
Fig. 16.9 Sterile gel is being applied over the area requiring radio frequency treatment
Fig. 16.11 Adjustment
control for the subcutaneous
thickness
Fig. 16.10 Settings for radio frequency
Pivot
distance between
electrodes
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M. Thomas and J. D’silva
a
b
c
Fig. 16.12 (a–c) The handpiece being gradually moved on the skin surface to heat the deeper layers
will get phagocytized and lost naturally. Usually in areas
of medium and large fat deposits where signicant heat
transfer takes place, lysis of fat cells will leave >100ml
of coagulated which will have to be evacuated by liposuction even if contouring is not required. This removal
of the heated uids is important to prevent subsequent
seroma formation and fat necrosis that may be caused
due to pooling of heated uids in operated areas.
(Fig.16.13)
11. RFAL provides excellent contraction of the soft tissue
and thus a Surgeon can achieve consistent and reproducible results without the complications of aggressive,
supercial liposuction as seen in Fig.16.14a–c
Fig. 16.13 Liquied fat as well as blood products and serous uid is
Clinically the best results of RFAL with regard to circum-
aspirated to prevent seroma
ference reduction and linear skin contraction of arms and
abdomen were seen between the sixth week and the third
month postsurgery. No more changes were seen after the
third month when the results stabilized which indicated that
complete healing of the tissues took about 3months postsurgery. These results of tissue contraction were stable for an
additional 3months. The tightness of the skin and reduction
of the skin crepes are also tied to the coagulation of deep
networks of hypodermal septa and fascia [5]. The higher the
power of RF, the higher and faster is the temperature rise
which inicts more signicant coagulation and thermal contraction within safety limits. This immediate shrinking is
more pronounced in the abdomen (9%) than in the arms
(6%), and is due to the introduction of more RF energy in
abdomen than in arms.
16 Radio Frequency Assisted Liposuction
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265
Fig. 16.14 (a) Pre and
postradio frequency assisted
liposuction of the lower
abdomen and peri umbilical
area. (b and c) Pre and post
RFAL of the arms showing
the skin tightness after
aspirating 500cc fat from
each arm
PRE
a
PRE
b
POST
POST
PRE
c
16.8 Safety Features
RF comes with signicant safety features that minimize the
risk of thermal injury into the device platform. The thermal
injury is possible due to the signicant amount of radio frequency energy passing between the two electrodes. Without
POST
the real-time impedance measurement and the temperature
monitoring at both the electrodes, it would not have been
possible to achieve and maintain the goal temperatures for
the time required. Once the tissue reaches the preset temperature during the procedure, no more energy is delivered
by the device as there is an automatic cutoff and the energy
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M. Thomas and J. D’silva
is again delivered only when the temperature falls below the
preset temperature. The risk of burn and seroma may exist as
is the case with any energy-based device.
Another feature that prevents signicant burn injury during treatment is the “Temperature surge protection.” This is
an additional safety feature that helps the machine to recognize a sudden spike in the temperature of the tissues, which
immediately triggers cessation of energy delivery and can
stop and prevent impending complications from occurring.
Audio feedback is available from the device in the form of
a double time bell signal when the temperature is within two
degrees of the preset temperature, as well as a triple time bell
signal when the temperature of the tissue has reached the
goal, so from a practical standpoint, the surgeon will know
that the energy delivery has stopped. This helps the surgeon
from getting distracted as the surgeon need not look at the
screen to know what the temperature is and he/she can maintain focus on the treatment area and the patient at all times.
16.9 Pearls
1. Patience is required on the part of the surgeon for this
procedure.
2. The bipolar probes are delicate and slow movement is
required to heat the deeper tissues adequately.
3. It is suggested to not employ liposuction and radio frequency at the same time as it may cause deformities or
inadequate radio frequency treatment of the area. Treat
the area rst with liposuction and then undertake radio
frequency treatment without suction.
References
1. Paul M, Mulholland RS.A new approach for adipose tissue treat-
ment and body contouring using radiofrequency-assisted liposuction. Aesthet Plast Surg. 2009;33(5):687–94.
2. Lapidoth M, Halachmi S.Radiofrequency in cosmetic dermatology.
Aesthet Dermatol. 2015;2:1–22. https://doi.org/10.1159/000362747.
3. Paul M, Blugerman G, Kreindel M, Mulholland RS. Three-
dimensional radiofrequency tissue tightening: a proposed mechanism and applications for body contouring. Aesthet Plast Surg.
2011;35(1):87–95.
4. Divaris M, Boisnic S, Branchet M-C, Paul MD.A clinical and histo-
logical study of radiofrequency-assisted liposuction (RFAL) mediated skin tightening and cellulite improvement. J Cosmet Dermatol
Sci Appl. 2011;1:36–42. https://doi.org/10.4236/jcdsa.2011.12006.
5. Paul M, Blugerman G, Kreindel M, Mulhol-land RS. Three-
dimensional radiofrequency tissue tightening: a proposed mechanism and applications for body contouring. Aesthet Plast Surg.
2010;35(1):87–95.
6. Klein JA.Tumescent technique for local anesthesia improves safety
in large-volume liposuction. Plast Reconstr Surg. 1993;92:1085–98.
Laser Assisted Body Contouring
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ZoranŽgaljardić andIvonneŽgaljardić
17
17.1 Introduction
During the last 20years, there have been major technological
developments that have had a great impact on the surgical, as
well as nonsurgical body contouring. Although body contouring procedures are considered safe when performed scientically, the aim of technological implementations is to
diminish complication rate, reduce recovery, and improve
the overall result. That is how lasers, radiofrequency, and
ultrasound have found their advocates among the cosmetic
surgeons, especially during the last decade. Furthermore,
well-established studies have been conducted to ensure their
safety. According to the statistical report published by the
International Society of Aesthetic Plastic Surgery (ISAPS) in
2018, liposuction is the second most performed procedure
worldwide [1]. That is why it is no wonder that surgeons in
cooperation with technological companies are constantly
trying to improve this well-established technique. In this
chapter, we will focus on the implementation of the laser as
an adjunct to the standard liposuction technique—laserassisted lipolysis/liposuction.
17.2 Historical Background
oftheProcedure
During the last decade, various attempts have been made to
remove the subcutaneous fat in order to improve the physical
appearance. The oldest report dates back to 1921 when dr.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_17].
Z. Žgaljardić (*)
Maxillofacial Surgeon, Head and Neck Plastic Surgeon, Opatija/
Zagreb, Croatia
I. Žgaljardić
Plastic, Reconstructive and Aesthetic Surgeon, Opatija/Zagreb, Croatia
Charles Dujarrier performed fat removal surgery with a uterine curette along with extensive dissection on a female
dancer in order to improve the appearance of her ankles and
knees. Unfortunately, the procedure resulted with the injury
to the femoral artery and subsequent amputation [2]. Since
then, the technique has been fairly neglected among surgeons until the 70s when various surgeons worldwide report
different attempts to address the subcutaneous fat. The
breakthrough report is considered the one made by Arpad
and Giorgio Fischer, father and son gynecologist who presented a blunt cannula connected to a suction. [3] French
surgeons, Illouz and Fournier, further developed the technique. In 1982, Ilouz presented the liposuction technique at
the Annual Meeting of the American Society of Plastic and
Reconstructive Surgeons [4]. Liposuction was being performed under general anesthesia until 1987 when
Dermatologist Dr. Jeffrey Klein reported the use of, what is
today known as Klein’s formula. Large inltration solution
with local anesthetic enabled the procedure to be done without general anesthesia not only on small but on larger areas
without signs of system toxicity. By adding the epinephrine
in the inltration solution, Klein reduced the major blood
loss that was an enormous problem for the surgeons during
the procedure [5]. In 1963, Leon Goldman who is considered
the father of lasers in medicine published the rst report on
the impact of the laser energy on the skin. [6] In 1988. Hukki
etal. published an article on the effects of laser scalpels on
the skin and subcutaneous tissue [7]. In 1990, Dressel was
the rst to perform standard liposuction with laser ber
inside the cannula on a group of patients in order to get the
FDA (Food and Drug Administration) clearance.
Unfortunately, due to various imperfections in his technique,
the study did not show signicant benets compared to the
conventional tumescent technique [8]. Apeberg was next to
conduct studies on laser-assisted liposuction. He published a
report in 1994 about results of an FDA-approved study conducted in ve different aesthetic surgery clinics [9] which
was expanded in 1996. The results were still inconclusive but
he managed to prove diminished bleeding, pain, and edema
© 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_17
267
268
Wavelength (nm)
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Z. Žgaljardić and I. Žgaljardić
with a shorter recovery time [10]. Those ndings paved the
way to others clearly demonstrating the superiority of
laser- assisted liposuction over the conventional technique.
Apfelberg is usually cited as the rst to successfully implement the laser beam in the liposuction technique. In the early
2000, Goldman, Schavelzon, and Blugerman were rst to
report the scientic data that could support the effectiveness
of laser-assisted liposuction on bleeding control, superior
results, and faster recovery time [11, 12]. In 2002, Badin
etal. reported similar results. They also showed that the use
of laser promotes collagen shrinkage that reects in the nal
result as the skin tightening effect [13]. 1064nm Nd: YAG
laser (smartLipo, Cynosure) was the rst to be approved by
the FDA (31st October 2006) as the lipolysis device [14].
That approval paved the way for other companies to ood the
market with similar devices, popularized the use of laser in
body contouring surgeries, and enabled additional scientic
reports in order to improve the technique and its results.
17.3 The Science behind theTechnique
The photothermal effect is responsible for the interaction
between the laser energy and the surrounding tissue. Thus,
the generated effects in the tissue are a direct consequence of
“photohypertermia.” [14, 15] The surrounding tissue accumulates the applied laser energy and turns it into heat. The
accumulation of the heat leads to thermal damage. The last
can be divided into reversible and irreversible. To avoid the
unwanted thermal damage (burn), the laser beam needs to be
in constant movement. During that motion, the applied
energy undergoes two different physical processes: absorption and scattering. Two features are important for the lasertissue interaction: wavelength and the amount of energy
delivered [16]. Specic chromophores (light absorbing molecules in the tissue—fat, collagen(water), and blood vessels)
have different absorption coefcients and therefore have better absorption of the specic wavelength. Some articles show
that a specic wavelength is better in achieving superior
results according to the chromophore targeted. Parlette and
Kaminer report that the 924nm wavelength specically targets fat and is superior in fat dissolving. At the same time,
the absorption of that specic wavelength by the tissue collagen is low. Therefore, it is not as effective in achieving the
skin tightening effect [17]. On the other hand, 1064 nm
wavelength is better absorbed by the water molecules in the
surrounding collagen so has better skin tightening effect but
lesser fat-melting result. The scattered part of the applied
laser energy must not be forgotten. Although scattered at the
point of impact, at the end, that energy is also absorbed, only
diminished, just at the remote part of the tissue treated. The
higher absorption is, the lower the scattering is. Study conducted by Lukac et al. suggest that for the wavelengths
2
10
)
–1
0
10
Hb
–2
10
Absorption coefficient (cm
500
Diagram 17.1 Absorption coefcient of deoxygenated hemoglobin
(full line), oxygenated hemoglobin (dashed line), water (dotted line),
and lipid (dashed-dotted line) from 500 to 1600nm [21]
750 1000
1250 1500
HbO
H2O
Lipid
2
between 450 and 1800nm scattering are the dominant effect
in the tissue. [18] Optimal balance between absorption and
scattering is an imperative for a safe and effective technique.
The higher absorption is, more heat is accumulated in the
targeted tissue and thus the nal tissue temperature is hard to
control which can lead to unwanted thermal damage and
result in burns. In order not to cause a burn, the internal temperature should not exceed 50°C (optimal to be 48–50°C)
with an external temperature not higher than 41°C [16, 19,
20]. There is no consensus regarding the correlation between
the wavelength and its clinical effects on the tissue structures, like it was suggested by Parlette and Kaminer. Some
authors believe that the lead generator of all the laser lipolytic changes in the tissue (coagulation of blood vessels, disruption of fat cells, and stimulation of collagen formation) is
primarily the applied heat [14] (Diagram 17.1).
17.4 The Benets ofLaser Energy Applied
during theStandard Liposuction
Technique
Various studies have been conducted during the last 15years
and as a result lasers have found their way into the body contouring market.
The most important advantage of laser-assisted liposuction is the skin tightening effect. For that to occur, as previously described, the achieved internal temperature should be
within the 48–50 °C range. That temperature promotes
desired thermal injury within the dermis. Subsequently, the
physiologic healing process is initiated which leads to broblast stimulation and neocollagenesis. At the same time, the
heat itself shrinks the existing collagen. The nal effect is
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