CHAPTER 17
New Technology in Liposuction
Jason Pozner 
Barry E. DiBernardo Gabriella DiBernardo 
Daniel Kushner
It is clear to anyone who lives in the United States that fat loss is a topic of huge interest. We have only to switch channels on our television sets to see weight-loss reality shows or infomercials for body-toning devices. Newspapers are full of ads for new diet fads, such as the human chorionic gonadotropin (HCG) diet. Diet books are often on the best-seller list, and pharmacies sell millions of dollars’ worth of over-the-counter and prescription-based diet aids. Why do we have such an interest? Current data show that one third of the adult population in the United States are obese and another third are overweight, with the trend increasing. The overall business of weight reduction in the United States is a more than $30 billion industry, including pharmaceuticals, gyms, diet aids, books, and surgical and nonsurgical interventions.
Surgical interventions for body contouring are always popular procedures for plastic surgeons. In fact, data from the American Society for Aesthetic Plastic Surgery (ASAPS) in 2015 showed that liposuction was the most commonly performed surgical procedure in the United States (after breast augmentation), with more than 396,000 cases performed by core specialists. Liposuction is the number one aesthetic surgical procedure for men. This number may be far greater when laser liposuction procedures are factored in by the emerging market of noncore specialists. Other surgical body contouring procedures, such as abdominoplasty and lower body lifts, are also popular. However, the number of surgical procedures pales in comparison to nonsurgical aesthetic procedures performed, with 85% of the almost 13 million procedures being nonsurgical and 15% surgical. Predictions from ASAPS for 2016 include an increased number of surgical as well as nonsurgical fat removal procedures.
Why are nonsurgical procedures so popular? It is obvious that patients prefer lessinvasive procedures for a variety of reasons, including less pain, no anesthesia, and what is most important, a shorter recovery with less downtime. In fact, how many surgeons have the time in their lives for a surgical procedure on themselves, especially if it is for a small amount of fat removal? This answer is usually, “Very few.” When these questions are turned around:
■ How many of us have a small amount of fat we would like off of our bodies?
■ How many of us would like to have a safe, effective, noninvasive, minimal to no pain, no recovery procedure to have fat removed from our troublesome areas?
This answer is almost an overwhelming affirmative. In fact—several authors of this chapter have had this performed! If it is good for the goose—as they say.
There is a clearly established interest in nonsurgical fat removal for the general public. The first issue for a practitioner to determine is the viability for this procedure in his or her practice, and the second issue is to decide on which device to buy. Factors determining this include the price of the device, consumables, office space, who will perform the procedure, the legalities associated with the operator, and which devices are available and approved in one’s country of practice. This chapter will review the devices available in the United States and those pending FDA approval.
Cryolipolysis
CoolSculpting by ZELTIQ was cleared in September 2010 by the FDA for the noninvasive reduction of fat, and in Canada, the European Union, and other international markets for noninvasive fat layer reduction. According to the FDA approval, the device was cleared for the selective reduction of “love handles” or flank lipodystrophy.
This device was developed at the Wellman Center for Photomedicine at Massachusetts General Hospital in Boston, a teaching affiliate of Harvard Medical School, by Dr. Dieter Manstein and Dr. R. Rox Anderson. The technology is based on extensive scientific research that demonstrates that fat cells are more susceptible to extreme cold than other surrounding tissue. This process is known as cryolipolysis (cold lipolysis). Their original theory and research stemmed from literature reports of “popsicle panniculitis,” in which children who were given popsicles to eat for extended periods lost facial fat, and observations of patients exposed to cold who had fat layer reduction without skin injury. These observations led to animal studies that confirmed that when fat cells are exposed to specific controlled cooling, apoptosis (natural cell death) occurs, a process of natural fat cell removal that gradually reduces fat layer thickness. Specifically, the fat cooling causes crystallization in the fat cells and eventual fat cell death without injury to adjacent structures. The fat is then gradually removed over 2 to 4 months through a macrophage-mediated process.
After extensive study with animal models, human trials were done. Initial reports of these trials show very promising results, with 84% of patients showing noticeable improvement, with ultrasound measurements of fat reduction averaging 22.4% after one treatment. Lipid blood levels showed no changes during the postprocedure period. Since the initial multicenter trial, there have been numerous scientific reports attesting to the efficacy of this device, with averages of 20% to 30% fat removal per treatment.
The CoolSculpting system is shown, with available applicators and contours. The device’s base unit looks like a typical laser with a touch-screen control panel. Five applicators are currently available. The appropriate choice of applicator and contour depends on the area to be treated.
A disposable gel sheet is placed over the marked area to be treated to protect the skin and enhance the suction. A disposable cover is placed on the applicator to be used. The patient is photographed and the area to be treated is marked by the physician.
The covered applicator is placed on the patient by the technician and the suction is activated, causing the tissue being treated to be brought into contact with the cooling panels on the applicator. Once the suction is confirmed, cooling is activated, which causes the temperature to drop in the area between the plates to just about freezing. The newer applicators and software that became available in 2016 shorten the treatment time to 35 minutes.
