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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_577_Библиотеки_им_академика_М_И_Перельмана
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16 Buttock Reshaping: Principles andTechniques Using Vaser Device andFat Grafting
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209
Fig. 16.3 Square buttocks. Shape (1), Point C (2), V zoze (3), gluteal
muscle (4), lower inner gluteal leg junction (5)
Fig. 16.5 V shaped buttocks. Shape (1), Point C (2), V zoze (3), gluteal muscle (4), lower inner gluteal leg junction (5)
Fig. 16.4 Round buttocks with asymmetry. Shape (1), Point C (2), V
zoze (3), gluteal muscle (4), lower inner gluteal leg junction (5)
Fig. 16.6 A shaped buttocks. Shape (1), Point C (2), V zoze (3), gluteal muscle (4), lower inner gluteal leg junction (5)
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will be turned into transferable fat. This means that 1000 and
4000 cc of supernatant fat will turn into 600 and 2500 cc of
good fat.
16.3 Technology
In my experience, I have always used ultrasound-assisted
liposuction, being one of the pioneers in this technology
[5–7].
In the 1990s, I did use the SMEI rst-generation ultrasound device. However, since 2001, I started using VASER
third- generation ultrasound device, and I am still using the
latest VASER system, the PowerX, and the VASER smooth™
for cellulite treatment.
16.3.1 Parameters
– VASER: In my practice, I mostly used VASER 3.7mm 3
and 5 ring probes for emulsication and standard cases.
Power setting is normally 80% of the total in the thighs
and buttocks area. I use VentX cannula 3.7mm with the
full power of aspiration (Fig.16.7).
– POWER X: In my practice I use Triport cannula
3mm×20 cm, VentX SST-6 cannula 3.7 mm × 26 cm,
Mercedes cannula 4mm×30cm. This is what I use for
delicate tissue or in pre-treated fat or fat harvesting; for
deep medium to soft tissue or for rapid debulking, I use
the 4 or 5mm Mercedes cannula. The rotation angle is
normally 180 degrees for supercial treatment or 360 for
deeper. Rotation speed in deeper layer is between 340 and
420rpm; in supercial layer, I use a slower rotation speed
of 180–260rpm (Fig.16.8).
A. Di Giuseppe and F. Giovagnoli
Fig. 16.7 VASER system. Photo taken from VASER Solta Medical
User’s Guide [8]. Courtesy of Bausch, ©2022 Bausch Health Companies
Inc., All Rights Reserved
VASER system functioning has already been fully
explained in the chapter “Ultrasound-Assisted Liposuction
(UAL) with VASER Technology in Body Contouring.”
PowerX is a power-assisted device where different degree
of rotation and movement is used to reduce fat cells from the
treatment area. PowerX can be used alone or in combination
with VASER lipo during the evacuation part of the
procedure.
The two devices can be used together to better dene and
shape the body and extract fat for micro fat graft.
The PowerX lipo system utilizes a powered handpiece
that causes the attached cannula to rotate based on predetermined angle and speed settings, allowing physicians to
quickly debunk large areas of fat. The unique rotational
motion generated by the system and multiple user settings
enable optimal control during the procedure and reduce aspiration time and physician fatigue.
Rotational motion of the cannula allows physicians to
remove fatty tissue all the way around the cannula, rather
than just above or below the orice.
Fig. 16.8 PowerX system. Note rotation system from 90 to 360
degrees for better fat removal and sculpting. Photo taken from VASER
Solta Medical User’s Guide [8]. Courtesy of Bausch, ©2022 Bausch
Health Companies Inc., All Rights Reserved
16 Buttock Reshaping: Principles andTechniques Using Vaser Device andFat Grafting
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211
As in similar systems, a powered handpiece speeds up traditional liposuction cases and reduces physician fatigue.
I did test other systems on the market, and my impression
is that this one has minimal handpiece vibration.
VentX handpiece provides continuous, uninterrupted suction and prevents tube clogging.
In addition to speeding up the suction process, this reduces
fat cell trauma if the aspirate is harvested for fat grafting
procedures.
A wide range of settings allows tailoring the system as
desired. Supercial work is normally performed with a 180
degrees rotation angle. This is reserved for the high- denition
technique.
More aggressive large-volume fat removal is achieved
using a 360 degrees rotation angle in the deeper fat tissue.
The PowerX lipo system utilizes a rotational movement
of the cannula to quickly and effectively treat fatty areas
while minimizing trauma to the surrounding tissue. A surgeon has control over the rotation angle (how far the cannula rotates), and the rotation speed (how fast the cannula
rotates).
In deeper tissue, a higher rotation angle and speed allow
for efcient debulking of larger areas. For precision sculpting,
a lower rotation angle and speed can be chosen to treat more
supercial layers.
The PowerX lipo system also includes a specic Jog
mode that allows the physician to orient the openings of any
cannula tip to a desired starting point or “home position”
prior to the start of the rotation. This ensures that the cannula
orice is positioned correctly inside the body to reduce contour irregularities and allow for more supercial sculpting
applications.
16.4 Cellulite
Since 2015, I have introduced the VASER smooth™ device
for the treatment of cellulite, mainly on the buttocks, in my
practice.
As well known, two are the major causes of cellulite: the
rst is a hardening of the connective tissue support system of
fat. These are referred to as connective tissue (brous) septae. These are made of collagen. Over time, these septae
harden and contract. The contraction results in most of the
dimpled appearance that creates cellulite. Additionally, the
contraction leads to a blockage of the blood vessels and lymphatic system. The blood vessel blockage further hardens the
septae. The lymphatic blockage leads to thick, swollen
appearing skin. The second major cause of cellulite is protrusion of fat cells into the lower part of the skin known as the
reticular dermis. This protrusion results in the worsening of
the dimpling.
16.4.1 Hormonal Factors
Hormones play a dominant role in the formation of cellulite.
Estrogen may be the important hormone to initiate and
aggravate cellulite. However, there has been no reliable clinical evidence to support such a claim. Other hormones,
including insulin, adrenaline and noradrenaline, thyroid hormones, and prolactin, are all believed to participate in the
development of cellulite.
16.4.2 Genetic Factors
There is a genetic element in individual susceptibility to cellulite. Researchers have traced the genetic component of
cellulite.
16.4.3 Predisposing Factors
Several factors have been shown to affect the development of
cellulite. Sex, race, biotype, distribution of subcutaneous fat,
and predisposition to lymphatic and circulatory insufciency
have all contributed to cellulite.
16.4.4 Lifestyle
A high stress lifestyle will cause an increase in the level of
catecholamines, which have also been associated with the
evolution of cellulite. Certain dieting practices can also
diminish the level of these chemicals, and decreasing body
fat typically results in the appearance of cellulite
diminishing.
The VASER smooth Kit is an accessory to the VASER
lipo system and is intended for the fragmentation and emulsication of subcutaneous fatty tissues for aesthetic body
contouring. This includes the treatment of supercial fatty
tissue and brous septae responsible for uneven skin
appearance.
Objective is to enable the surgeon to emulsify fat, cut the
bands ultrasonically, and allow the surgeon to lipo-shift the
viable VASER fat into the treated area, smoothing out the
affected area (Fig.16.9).
The orientation of the handpiece is designed to help the
surgeon to know where the fragmentation edge is located.
The probe expressively designed for cellulite treatment is
the V-probe (showed in Fig. 16.10a), which I personally
introduced in the past for gynecomastia treatment. This helps
break the bro-septa emerging from the underlying muscle
or from the fascia layer.
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A. Di Giuseppe and F. Giovagnoli
The second probe (showed in Fig.16.10b) is designed to
emulsify with the tip and the lateral part of the shaft and to
break the brotic supercial septa with the medium part of
the shaft, which presents a pointed side, designed to cut
instead of emulsify (showed in Fig.16.10c).
In my personal technique, I normally use a 3.7mm 2-ring
Vaser probe, the Vaser power set at 70–80% of the total
power, by working in a continuous mode.
For beginners, it should be advisable to drop the power to
60% and using the VASER mode initially to prevent burns or
skin necrosis, when working close to the subcutaneous
tissues.
In my experience, with more than 8000 body contouring
procedures, never experienced such a kind of complication.
Regarding power X, I set up the angulation at 180 degrees
and at 260rpm (rotation per minute speed).
VASER smooth device must be used only by a real experienced surgeon, as it is designed as a special probe, which
emulsify on the top of the shaft while it cut the brotic zone
of adherence of the cellulitis with a central part of the probe.
Fig. 16.9 VASER smoothTM handpiece. Photo taken from VASER
Solta Medical User’s Guide [8]. Courtesy of Bausch, ©2022 Bausch
Health Companies Inc., All Rights Reserved
This cutting edge must be manipulated with great care:
some small perforator vessels could emerge from the underlying fascia, which vascularize part of the thigh, which the
cutting probe could sever.
Thus causing problems of vascularization of the thigh
(Fig.16.10).
I present two cases of accomplishing VASER lipo, cellulite treatment with VASER smooth, and fat transfer to C
point (lateral trochanter depression).
Case 1
The rst patient is a 43-year-old woman presenting a severe
degree of cellulite, body asymmetry with different positions
of gluteal fold, and lipoditrophy. Buttock frame A moderate
with C point depression. Surgical plan: reshaping lateral
anks with VASER lipo, cellulite treatment with VASER
smooth, and fat transfer to C point at the gluteal depression
(Fig.16.11).
Case 2
The second patient is a 43-year-old woman whose buttock
frame is square, cellulite is diffused all over the buttocks,
the lateral thighs and lateral anks are too much represented, and the C point presents moderate depression
(Fig.16.12).
As a comment, VASER smooth has much-improved skin
surface quality and appearance in initial and medium
degree of cellulites, in buttocks and thighs. The double
action of the VASER smooth probe allows a gentle breaking of the bro- septa and, simultaneously, a lipo-shifting of
the emulsied fat, which prevents the recurrence of the skin
contracture and smooths the surface and the contour of the
treated areas.
ab c
Fig. 16.10 VASER smoothTM probes. (a) 4.5mm 2-groove (V-probe). (b) 3.7mm 3-groove. (c) Side style rendering. Photo taken from VASER
Solta Medical User’s Guide [8]. Courtesy of Bausch, ©2022 Bausch Health Companies Inc., All Rights Reserved
16 Buttock Reshaping: Principles andTechniques Using Vaser Device andFat Grafting
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Fig. 16.11 Pre and 6months post op
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Fig. 16.12 Pre and 6months post op
16.5 Fat Harvesting
With my technique, I emulsify fat with VASER liposuction;
then I use the REVOLVE™ system to wash, centrifuge, and
concentrate fat, removing oil, triglycerides, blood, and uid
excess. Extra uid is collected in a standard disposable canister, or a washable canister can treat emulsied fat (Fig.16.13).
I already reported about the functioning of the REVOLVE™
system in the chapter “Breast Fat Augmentation: Step-byStep Technique and Ultrasound Contouring of Donor Area”
(Fig.16.14).
Fat ready to be transferred is collected in 60mL syringes
and left in a rack for further decantation. To follow, fat is
transferred with a connector to 10mL syringes, in order to
decrease depression on the fat cells over inltration
(Fig.16.15).
I use a 3mm cannula with one hole for fat deposition in
a multilayer fashion. The consistency of fat harvested with
the REVOLVE™ system is thicker and does contain less
uid: as a consequence, it is more difcult to be transferred,
as less aqueous, but it stays longer and gives less post-op
swelling.
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A. Di Giuseppe and F. Giovagnoli
Fig. 16.13 Canister
Fig. 16.14 REVOLVE™ system
Fig. 16.15 60mL syringes ready for transferring
16.6 Gluteal Sculpting
Case 3: Medium-Framed Patient with a Sufcient Fat
A 45-year-old woman, A shape buttock, with good anatomy
of the gluteal region, dimension, and volume. She presents
carency on the C point, excess in the lateral anks and mild
lipodystrophy of the trochanter. The surgical plan will
enhance lower lateral buttock volume, improve the transition
zone, ll the C point, and reduce anks and torso.
VASER plus REVOLVE™ were used. A total of 750 cc of
fat were placed to better dene the lateral contour of the gluteal region and mildly enhance the total projection of the
muscle. Due to age, the patient required better contouring
and shape defects without affecting buttock volume
enhancement.
One-year post-op result shows a change into a more
rounded A frame (Figs.16.16 and 16.17).
Case 4: Medium-Framed Patient with a Sufcient Fat
A 36-year-old woman, round shape buttock, with asymmetry
of anks and trochanter height. The patient complained
mainly about a at buttock shape, looking for enhancement
and projection.
VASER liposuction to abdomen, anks, torso, banana
fold, and anterior thighs and REVOLVE™ system to harvest
800 cc of total fat, 350 cc on each buttock for augmentation
and 100 cc and more used for reshaping and contouring.
16 Buttock Reshaping: Principles andTechniques Using Vaser Device andFat Grafting
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Fig. 16.16 Analysis and
planning of buttock
contouring
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One-year post-op result shows a similar round frame with
better lateral buttock projection (Fig16.18).
Case 5: Medium-Framed Patient with Large Amount of
Fat
A 25-year-old patient, square shape buttock, 74kg weight,
complaining at buttocks, back rolls and abdominal and
anks excess. She does present short buttocks, no C point
depression, but the total height of the gluteal muscle is decient. Surgical plan: VASER liposuction to torso, anks,
upper and lower abdomen. 1400 cc of total fat harvested,
700 per side, to lengthen buttocks and achieve more
roundness.
One-year post-op result shows an A round frame achieved
(Fig.16.19).
Case 6: Medium-Framed Patient with Sufcient
Amount of Fat
A 39-year-old patient with a round frame, complaining of
back rolls and looking for better denition and more roundness of buttocks. VASER liposuction to torso, anks, and
abdomen. A total of 1200 cc of fat was harvested. 600 cc for
each side for reshaping, recontouring, and enhancing
projection.
One-year post-op result (Fig.16.20).
Case 7: Medium-Framed Patient with Large Amount
ofFat
A 24-year-old woman, round frame, complaining of cellulites,
large unshaped buttocks, 3D thigh excess, and large waist.
Surgical plan was: VASER liposuction of torso, anks,
and anterior thighs. VASER smooth for cellulites treatment
buttocks and posterior legs. Fat transfer to C depression, to
lower and medium buttocks for contouring, reshaping, and
enhancing.
1000 cc of fat transferred (Figs.16.21 and 16.22).
Case 8
A 38-year-old patient, with slim frame but unhappy about
the contouring of anks, poor denition and at buttocks.
Droopy buttocks, and banana fold deformity.
The surgical plan included anks and abdomen denition,
liposuction to harvest fat and fat transfer to the buttocks to
increase shape and contouring—more denition of the
abdominal area to enhance athletic shape (Fig.16.23).
Case 9
A 44-year-old patient, two pregnancies, overweighted, with
bulge and apron of the abdominal wall. On the back, rolls,
heavy anks, back rolls and torso laxity. Complaining also
for at and unshaped buttocks. Surgery consisted of VASER
lipo of upper and lower abdomen, back rolls, and tors. A total
of 4500mL was aspirated. 600mL of fat inltrated each buttock. Pre-op photos, 6 months post-op photos, and photos
taken at the end of surgery are presented. Note the great skin
retraction of the abdominal skin which involved mainly the
lower abdominal apron and bulge, avoiding the need for an
abdominoplasty. In addition, supercial VASER was performed to enhance skin tightening capabilities, obtaining a
unique effect of skin tightening (Fig.16.24).
Case 10
A 33-year-old girl, 65kg weight, 165cm height for stubborn
fat deposit in the upper and lower abdomen and hip deciency. From the analysis of the body frame, there is a lack
of convexity line of the oblique view of the patient abdomenhips relationship. Heavy anks and hip indentation are the
oblique features of this patient. From the back view, heavy
anks are connected with back rolls, and the axillary area
lacks denition. Regarding buttocks, they look at and not
rounded: the body frame clearly indicates the need for hip
compensation with fat and enhancement of the fullness and
projection of both buttocks (Figs.16.25 and 16.26).
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A. Di Giuseppe and F. Giovagnoli
@AlbertoDiGiuseppe @AlbertoDiGiuseppe
a
@AlbertoDiGiuseppe @AlbertoDiGiuseppe
b
Fig. 16.17 45-year-old woman, A shape buttock. VASER to anks, thighs, and buttocks. 750 cc of total fat transfer (C point, transition zone, buttock lateral and medium regions). Pre op (a, c). 1year post op (b, d)
cd
16 Buttock Reshaping: Principles andTechniques Using Vaser Device andFat Grafting
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217
@AlbertoDiGiuseppe @AlbertoDiGiuseppe
a
b
@AlbertoDiGiuseppe @AlbertoDiGiuseppe
Fig. 16.18 36-year-old woman, round shape buttock. VASER to abdomen, anks, torso, banana fold, and anterior thighs. 800 cc of total fat transfer. Pre op (a, c). 1year post op (b, d)
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A. Di Giuseppe and F. Giovagnoli
@AlbertoDiGiuseppe @AlbertoDiGiuseppe
a
b
@AlbertoDiGiuseppe @AlbertoDiGiuseppe
c d
Fig. 16.19 36-year-old woman, round shape buttock. VASER to abdomen, anks, torso, banana fold, and anterior thighs. 800 cc of total fat transfer. Pre op (a, c). 1year post op (b, d)
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