Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_591_Библиотеки_им_академика_М_И_Перельмана
.pdf
29 Critical Analysis andtheFuture ofLiposuction forBody Contouring
https://t.me/medicina_free
treat the whole body using 60ml syringes to aspirate and inject fat. In the beginning,
we used catheter tip syringes, which would often break at the tip, until we started
using Toomey tip syringes, which solved this problem. I abandoned the use of the
liposuction machine, and all my face and body contour work were performed using
syringes (Toledo 1991a).
From 1988, I had been performing liposculpture with syringes only, aspirating
and injecting fat, and it was in 1990 when Carson Lewis, one of the founding members of LSNA (Lipoplasty Society of North America), and Frederick Grazer, who
organized courses for ASPS (American Society of Plastic Surgery), saw my lectures
in a small meeting in Beverly Hills (Toledo 1990b) and invited me to give courses
on the technique. Carson organized live surgery workshops in his La Jolla Clinic
(Toledo 1991b) and Fred in his Newport Beach facility. These meetings were
attended by plastic surgeons from all over the United States, and I started being
called to organize body and facial contour teaching courses at the three important
societies of plastic surgery, the ASPS (Toledo 1990c) (American Society of Plastic
Surgery), ASAPS (Toledo 1990d) (American Society for Aesthetic Plastic Surgery),
and LSNA (Lipoplasty Society of North America) (Toledo 1990e), which I did for
over 15 years. LSNA organized two events every year back to back with the ASPS
and ASAPS yearly congresses, with the sole purpose of teaching lipoplasty. LSNA
ended up being absorbed by ASAPS.
Surgeons knew that it was perfectly possible to perform a full-body liposculpture
using only syringes and a few cannulas. Soon I realized that the medical instruments’ market was not pleased with this breakthrough. The industry needed to sell
expensive machines. More and more companies were starting to sell aspirators with
different names. Plastic surgeons were designing different cannulas and had their
names connected to the technique.
When I moved to Dubai in 2005, my nurses were not used to my work with the
syringe where they have to be extra attentive and busy changing syringes and cannulas and preparing fat for reinjection. I limited the use of syringes to small procedures and when fat injection was necessary.
443
Supercial Liposculpture
In 1989, I invited the Italian surgeon Marco Gasparotti to come to Brazil and lecture
at the symposium I organized called RAPS, Recent Advances in Plastic Surgery
(Gasparotti 1989). I had heard his technique was slightly different but had not yet
seen him operate. For the sake of the program and the annals of the meeting, we
decided to call Gasparotti’s technique radical liposuction. Seeing him operate, I
realized he was performing supercial liposuction. After the meeting, we established a long-term collaboration, he visited me a few times in São Paulo, and I
444
https://t.me/medicina_free
would travel to Rome to see him operate. I combined his technique with syringe
liposuction and started performing supercial syringe liposculpture (Toledo 1992c),
aspirating and injecting fat. Illouz had just published his book Body Sculpturing by
Lipoplasty (Illouz and DeVillers 1989), in which he was adamant that every liposuction should be deep, leaving at least a 1cm layer of fat attached to the skin. He had
published a body map, dividing the body into ve areas, easy to treat, moderate,
difcult, very difcult, and taboo, areas that should not be treated at all. This map is
still a very good guide to young surgeons, starting with the procedure.
Working with Marco, we realized that it was possible to increase skin retraction
by aspirating fat subdermally, very close to the skin. But it was important to aspirate
in a uniform mode, to avoid irregularities and produce a good skin retraction.
Together, Carson Lewis, Marco, and I published in 1993 with Springer-Verlag the
book Supercial Liposculpture – Manual of Technique (Toledo etal. 1993), to lay
the ground work and explain how we performed the technique. After the book was
published, we were invited to do live courses in North America and Europe. Many
surgeons heard about the idea and started performing supercial liposuction without
the necessary training, and obviously many irregularities were created.
L. S. Toledo
Power-Assisted Liposuction (PAL)
Liposuction can be a very strenuous operation. The in and out movements repeated
for a few hours can be tiring and often even worse when treating secondary cases
with brosis. The aspiration can be difcult at times and require special cannulas
and instruments. Power-assisted liposuction (PAL) was developed to ease the movements of fat aspiration. The rst machines used compressed air and would shake too
much, eliminating any possibility of renement. In 2015, I bought the German
Moller Vibrasat (Fig.29.6), the last generation of electric vibrating machines, which
abolished the handpiece vibration (Fig.29.7). Aspiration became easier and noiseless, which is very helpful in long procedures. It also has an integrated heating
system for the local anesthesia, a pump for the anesthesia injection, a suction device,
and a vibrating handpiece.
29 Critical Analysis andtheFuture ofLiposuction forBody Contouring
https://t.me/medicina_free
Fig. 29.6 The Moller
Vibrasat PAL machine. It
heats and inltrates
anesthesia and aspirates fat
with vibration
445
Fig. 29.7 The Moller
Vibrasat handpiece is
steady and allows for a
rened liposuction
446
https://t.me/medicina_free
L. S. Toledo
Internal Ultrasound-Assisted Liposuction (UAL)
In 1992, the rst-generation internal ultrasound machines appeared in the market.
The goal was to provoke an internal dermal “burning” and increase skin retraction.
A Brazilian plastic surgeon from São José do Rio Preto came to my clinic to show
me the ultrasound machine he had developed. He oversaw the procedure taking
place, explaining that the ultrasound probe had to be constantly moved with in and
out movements, never stopping in the same place to avoid burns and necrosis. The
voluntary patient was a young girl with only a small lateral thigh adiposity, chosen
to be the “perfect candidate” to demonstrate the technique. After the probe had been
passed and the fat had “melted,” I used the syringe to remove the excess fat. The
patient went home but called me in the middle of the night saying her right thigh
was much bigger than the left. I rushed her to the hospital where I aspirated about
500ml from a hematoma. This was a hematoma from the lateral thigh, an area without any major vessels. I compressed the area, and the result nally and thankfully
was not bad, but I immediately stopped using the device.
Ultrasound-assisted liposuction (UAL) had been shown by Klohen (Kloehn
1996) and popularized by Zocchi (Zocchi 1999). On my next trip to the United
States, I realized ultrasound liposuction was now a big commercial hit with the
launching of the second-generation Lysonix machine (Fig.29.8). In order to be
licensed to perform this technique, surgeons had to undergo a training course. The
machine cost about US $40,000, and the company organized courses all over the
country charging doctors US $2500 to get the needed certication. It was a moneymaking machine. This wave lasted for about 1 year. When reports of complications
(Illouz 2014) started being published and shown in meetings, doctors stopped using
the technique and tried to sell their machines. An Ultrasound-Assisted Lipoplasty
Task Force was created (Fredericks 1999) to report on the safety and efcacy of this
new lipoplasty procedure, which was soon abandoned.
Fig. 29.8 The internal
ultrasound was abandoned
when reports of tissue
burns and irregularities
were published
29 Critical Analysis andtheFuture ofLiposuction forBody Contouring
https://t.me/medicina_free
447
The third-generation machine called Vibration Amplication of Sound Energy at
Resonance (VASER) limited the power of the ultrasound energy and is less harmful
to blood vessels, lymphatics, and nerves, but we still see irregularities, seromas,
neural pain, and tissue burns. I have not seen the need to use these machines, but
there is a media frenzy now, and doctors who do not use them are not considered up
to date by prospective patients.
External Ultrasound-Assisted Liposuction (XUAL)
In 1997, I learned that we could use an external ultrasound device developed by
Silberg (Silberg 1998) and the Wells Johnson Company to treat adiposities
(Fig.29.9). The idea was that the fat layer could be reduced just with the use of the
external ultrasound with no need to perform an invasive treatment. I bought the
machine and started using it in Brazil and quickly determined that results were better and more reliable if, after using the ultrasound, I aspirated the excess fat. I soon
realized I was using the machine to justify the money I had spent and to be part of
the “modern trend.” The question was if the skin retraction was better with the use
of the machine or not.
Fig. 29.9 The external ultrasound (XUAL) was used for a while, but also abandoned
448
https://t.me/medicina_free
L. S. Toledo
Laser Liposuction
Internal laser was rst used for lipoplasty in 1990 by Thomas Dressel from the
United States. He used a Nd-YAG laser, with a glass ber inside the cannula. The
indications were for brotic and dense areas and for vascularized tissues. The cost
of the equipment was too high, and the laser increased the complexity of the procedure. Results were the same as traditional lipoplasty. The method was abandoned.
In 2007, our hospital bought a Smartlipo laser machine (Fig.29.10), and we used
it for a few years. The main indication for me was when a patient asked if I was
performing “laser lipo” and I could say that I was. I would use the machine and
obtain the same results (Fig.29.11).
Fig. 29.10 I used the Smartlipo internal laser in areas that needed more skin retraction, but the
result was similar to supercial liposuction
Fig. 29.11 The use of
internal laser before
aspiration of the neck
29 Critical Analysis andtheFuture ofLiposuction forBody Contouring
https://t.me/medicina_free
449
External Laser
I travelled a lot to many South American countries to lecture. In 2000, while in Cali,
I met the Colombian plastic surgeon Rodrigo Neira, who was using an external laser
to treat the fat before aspiration. Low-intensity laser therapy was normally used for
postoperative and wound treatment at a potency of 50 mw at 660nm. Neira had
used it in 700 patients over 2 years to improve his liposuction results. I was organizing a meeting in Porto Alegre with Nelson Heller and invited him. He came, lectured, and performed demonstration surgeries (Toledo and Heller 2001).
I used the laser (Fig.29.12), and in 2005, we wrote an article about our use of
low-level laser-assisted liposuction (Neira etal. 2006). Neira claimed the 4L technique was an excellent adjuvant tool for the surgeon practicing liposculpture. His
idea was that the low-level laser would create a transitory pore in the cell membrane
of the adipocyte to move fat from inside the cell to the interstitial space outside
without killing the cell. The technique had been performed successfully in invitro
and human adipose tissue cultures. The theory was to decrease the surgical trauma
of liposuction by protecting and preparing tissues for the surgical trauma, modulating the inammatory response to prevent short- and long-term side effects of surgery, and improving the quality and quantity of the healing process by accelerating
recovery time, modulating secondary cicatrization, and preventing postoperative
neuralgias.
The indications were to facilitate suctioning, shorten surgical time, decrease the
risk of infection, decrease inammation, improve skin retraction, and improve
recovery. After using the external laser for a period of 6 months, I realized it did not
facilitate suctioning or shortened surgical time. The laser probably decreased the
risk of infection and inammation, and recovery was slightly improved. But did it
improve skin retraction? I could not nd any clinical demonstration that retraction
was any better.
Fig. 29.12 The external
laser was also used to
provoke skin retraction
after liposuction
450
https://t.me/medicina_free
L. S. Toledo
J Plasma
This is another new name and new trend to try to improve skin retraction. A disposable device in inserted under the skin, which releases helium gas and radiofrequency
(RF) to create a stream of energy. This energy generates heat to contract the skin
while, at the same time, excess helium gas cools the treatment area. The idea is to
contract the tissues just under the skin. Since the handpiece is expensive and disposable and its results are still not clear, we will have to wait for further research on the
technique.
High Denition
Patients mostly wanted to get rid of excess fat, and a at abdomen was what a high
percentage of them were looking for, obtained by combining abdominoplasty with
liposuction. In 1984, Jorge Psillakis published his modication of the traditional
abdominoplasty (Psillakis 1984), adding contour and denition comparing the
abdominal shape with the music instrument lyre. This was probably the rst article
written explaining an attempt to improve the anatomy accentuating the shape of the
recti and obliquus muscles. His technique involved undermining the major oblique
musculature to reduce the diameter of the waist and also reduce the diameter of the
superior abdomen by resecting cartilage from the seventh and eighth ribs when the
anterior projection was exaggerated.
In 2006, Gasparotti (Gasparotti 2006) used the term 3D in an article, and soon
many other authors started using different names to describe their modications,
such as high denition (HD) and even 4D (!), adding another dimension to their
procedures. I had been performing supercial liposculpture and observed that my
female patients only wanted denition on the linea alba (patients joked about wanting a “Champagne groove”) and on the V shape formed by the oblique muscles
(Toledo 1999) (Fig.29.13).
The rst presentation I watched about abdominal etching to create a six-pack
effect was in the early 1990s by Larry Schlesinger, from Honolulu. He had many
male body builder patients who wanted to accentuate the abdominal muscles, and
he created the etching technique to produce a six-pack denition. There was a lot of
criticism, and the consensus at the time was that this was not a technique for women,
since it could masculinize the women’s body. In a later meeting, Larry showed a
complication—a patient to whom he had created a six-pack had put on weight and
was now overweight but still showing the six-pack design on his abdomen.
The combination of etching and high denition has become very popular recently.
Some surgeons became specialists in creating “athletic” bodies, the shapes being
created by areas of liposuction and fat injection creating the highs and lows, volumes, and depressions.
29 Critical Analysis andtheFuture ofLiposuction forBody Contouring
https://t.me/medicina_free
451
Fig. 29.13 Before and 6 months after supercial syringe liposuction of the abdomen and anks
with denition of the linea alba and oblique muscles
Noninvasive Body Contour
In 2013, I started using cryolipolysis (Toledo 2015) for local reduction of fat deposits to reshape body contours. I believe liposuction is the best, safest, and most reliable technique to remove localized fat when performed by qualied plastic surgeons.
But there are patients who do not want a surgical procedure, are afraid of anesthesia,
or simply do not have the money for it. With these patients in mind, I started using
the Coolplas machine (Fig. 29.14). I knew there were other more expensive
machines, which used expensive disposable parts for every treatment. The disposable gel pads of Coolplas are cheap cotton sheets saturated in a solution that protects
the skin and ensures proper thermal coupling during a procedure.
Cryolipolysis is a noninvasive procedure to remove unwanted body fat by cooling the fat deposits and provoking subcutaneous fat reduction through cellular apoptosis. “Cellular apoptosis is a normal biological process whereby cells are eliminated
as part of normal cell turnover. The injured cell enters an orderly, regulated process
of gradual degradation and is absorbed by the body’s immune system over time,
usually 2 months. This reduces the subcutaneous fat tissue without damage to the
452
https://t.me/medicina_free
Fig. 29.14 The
cryotherapy Coolplas
machine. Non-surgical fat
reduction
L. S. Toledo
overlying skin.” The procedure is simple and fast (45–60 min), and after the treatment, the patient can go back to normal activities. There is no downtime and no
anesthesia, and it can be performed during a lunch break. The treatment can be
repeated, if necessary, after 2 months. Cellular elimination through apoptosis is in
contrast to cellular necrosis, or uncontrolled cell death, in which an acute injury to
the cell leads to lysis of the cell. Cellular necrosis triggers an aggressive inammatory response leading to brotic scar tissue formation, which is not observed with
cellular apoptosis.
I had two machines in the ofce, and they worked very well. Patients were happy
with the reduction of the fat deposits without having to undergo surgery. The reduction is uniform. It is not possible to “sculpt” the area to be treated as we can do with
liposculpture. But these patients do not mind as they wanted a bulge reduction, and
the Coolplas could achieve that in the majority of the cases. There are obviously
more expensive machines, but this is a cost-effective treatment that has been well
accepted by my patients (Fig.29.15).
Соседние файлы в папке Библиотека им академика М.И. Перельмана