Preoperative preparation

Patients are evaluated for potential fat reduction and skin laxity improvement. When treating specific areas, these areas of adiposity are marked in a standard fashion, in addition to 5 × 5 cm squares representing the areas of skin laxity targeted for energy application. Approximately 50 to 100 mL of tumescent fluid is administered per 5 × 5 cm sector ( Fig. 1 ). This procedure is routinely performed with oral and local anesthesia only, but may be supplemented with intravenous (IV) sedation, epidural block, or general anesthesia.

Application of tumescent fluid 50 to 100 mL per sector.

It is essential to manage patient expectations during the initial consultation. Patients must understand that the skin tightening effect hinges on several variables, including age, genetics, and skin condition from environmental factors, such as smoking and sun exposure.

Surgical technique

The laser system (Triplex; Cynosure, Westford, MA, USA) allows individual as well as sequential emission of 1064-nm, 1320-nm, and 1440-nm wavelengths. Energy is delivered to the subdermal tissue through a 600-μm or 1000-μm fiber threaded through a 1-mm microcannula that extends 2 to 3 mm beyond the distal end of the microcannula. When the microcannula is inserted into the tissue, the laser is activated and the microcannula is moved slowly and evenly through the deep fat layer with a 1064-nm to 1440-nm combination, or the superficial subdermal layer with a 1064-nm to 1320-nm combination ( Fig. 2 ). For ideal absorption and performance, wavelength combinations are used for preferential target affinity of fat and water, respectively.

Diagrammatic representation of placement of deep laser energy for adipocyte and fibrous disruption.

Using the biplanar technique, adipose cells are disrupted, resulting in a more liquefied material that can be removed through a smaller cannula. This smaller cannula refines the removal, particularly close to the surface, thereby reducing potential contour irregularity that can be seen with larger instrumentation. To achieve increased skin elasticity and tightening, surface temperature goals of 40°C to 42°C superficially, and deep temperature goals of 45°C to 47°C are delineated. The lower temperature goal is used for darker skin colors. Achieving and maintaining these temperature goals uniformly is essential to achieving optimal efficacy.

Safe energy delivery is monitored via an accelerometer delivery system (Smart Sense; Cynosure) attached to the laser handpiece, used to minimize the occurrence of localized thermal damage during treatment. The handpiece contains a motion-sensing feedback chip that provides constant information of cannula movement to the laser device. Slower movement of the handpiece triggers a reduction in laser power. If the handpiece stops, energy delivery ceases within 0.2 seconds. This safety feature prevents excess accumulation of energy in a given area. Temperature safety is measured with a thermastore probe at the tip of the cannula, which is set for a safe range according to the above-mentioned parameters. When the threshold is reached, the laser automatically stops firing.

A 2-layer/2-step technique is used in which the deep fat layers (1–3 cm below the epidermis) within the premarked squares are treated first (see Fig. 2 ). Insertion of the microcannula is facilitated with the use of 1-mm incisions made with a number 11 blade for appropriate access to the treatment area. The superficial subdermal layer (0.5 cm below the epidermis) is treated in the second step of the 2-layer technique ( Fig. 3 ). Aspiration is performed with a standard 3-mm suction cannula to remove any remaining fat, disrupted cells, and free fat oils. Clinical examples are shown in Figs. 4–6 .

Superficial laser application just under the dermis, with visualization of helium neon guiding beam.

Clinical example of back rolls treated with LAL. Preoperative ( A ) and 3 months postoperative ( B ).

Clinical example of brachial fat removal and skin tightening from laser. Preoperative ( A ) and 3 months postoperative ( B ).

( A, B ) Clinical example of neck treatment with LAL in a 48-year-old patient, 3 months postoperative. Note slight muscle bands evident.

Optimization of this procedure hinges on proper delivery of energy while maintaining an appropriate safety margin. Inadequate tightening can often be the result of insufficient temperature attainment necessary to achieve the desired effect. Too much energy applied in one area can result in excessive heat build-up and fat necrosis. If too much heat is applied superficially, the result will be skin blistering, burns, or pigmentation changes. If used properly, the built-in safety mechanisms will help control temperature and avoid harmful buildup of heat.

Postoperative care

Firm pressure dressings are applied to the wounds on completion of the aspiration, and compression garments are worn for 3 to 4 weeks postoperatively. Dependent incisions are left open for drainage, and oral antibiotic prophylaxis is administered.

Skin and tissue firmness is examined 1 week postoperatively. Excessive swelling or dense edema is treated with the use of the Triactive Device (Cynosure) or equivalent massage, edema reduction, and lymphatic drainage enhancement for 3 weeks postoperatively. Patients are reminded of the time necessary for skin changes to occur during the dynamic fibroblast stimulation period (90 days). If further enhancement of skin is desired after 3 months, acceptable external skin devices can be applied, and additional treatments in adjacent areas can be performed after tissue effects have subsided.

Complications and management

Complications of LAL include blisters, end hits, burns, blowholes, prolonged edema, heat/pressure problems, neurapraxia, permanent nerve damage, contour irregularity, minor asymmetries, and insufficient effect. If performed properly, the occurrence of these complications is rare.

Summary

Previous work has led to an improvement in the safety and an enhancement of the cosmetic results of LAL. By reducing blood loss, minimizing complications, and promoting skin tightening, LAL has proven to be a safe and effective body contouring procedure in appropriate candidates. Future applications of fiber-deliverable energy will aim to address the superficial irregularities of the skin, such as dimpling, scars, and cellulite.

Preoperative preparation

Even though UAL has expanded the parameters for liposuction patient selection, one criterion that remains unchanged is the patient’s candidacy to undergo an elective surgical procedure. Once this has been established, preoperative preparation may proceed.

Preoperative markings are performed in the standing position. There are 5 distinct anatomic areas that should be avoided in patients undergoing UAL. These areas, termed the “zones of adherence,” include the gluteal crease, the lower lateral thigh area of the iliotibial tract, posterior distal thigh above the popliteal crease, midmedial thigh area, and lateral gluteal depression area. Violation of these areas often leads to iatrogenic contour deformities. During the preoperative marking process, it is essential to plan the placement of access incisions carefully. UAL requires a greater number of slightly longer access incisions to accommodate the skin protectors and to avoid placing torque on the ultrasonic probe over curved anatomic areas.

VASER probe selection must consider the characteristics of localized fat in the region to be treated. The characteristics of fat cells in different regions of the body differ with respect to collagen structure and septi among the fat cells, as described by de Souza Pinto and colleagues. Knowledge of these differences is essential for probe selection to achieve optimal outcomes.

Penetration of tissue is influenced by probe diameter and the number of grooves at the tip. For a probe of a given diameter, more grooves emulsify fat tissue more efficiently. However, they do not penetrate fibrous tissues easily because of vibratory energy that is transferred to the sides of the probe as opposed to the front surface. Fibrous tissues are better addressed with probes with fewer grooves. Smaller-diameter probes also penetrate fibrous tissue more easily. The 3.7-mm probes achieve rapid debulking and contouring of medium to large volumes of soft to fibrous tissues. The number of grooves at the tip of the probe will vary according to the fibrous nature of the anatomic area. For treating smaller, soft to extremely fibrous localized fat deposits in sensitive areas, fine contouring is achieved with 2.9-mm probes.

In general, continuous mode should be used for fibrous tissue, faster fragmentation, and times when tissue emulsification is not readily achieved in VASER mode. VASER mode is more suited for delicate work, finer sculpting, or softer tissues. The device must be adjusted such that the probe moves smoothly through tissue.

Experience and practice have delineated application times. In general, 1 minute of application time may be used per 100 mL of infused solution in VASER or continuous mode. Loss of resistance to probe movement in all intended areas can be considered the surgical endpoint. Following emulsification, aspiration can be performed with suction-assisted or power-assisted liposuction.

Surgical technique

The prone position provides good access to the back, flanks, lateral thighs, and superior posterior thighs. General endotracheal anesthesia is preferred for patients requiring prone positioning and for large volume aspirations. Many surgeons also prefer the lateral decubitus position, which requires one additional patient repositioning. Despite additional repositioning, some authors maintain that the lateral decubitus position offers better access with less trauma and is particularly helpful for evacuating large volumes from the flanks and back with the goal of creating more aesthetic waistlines. Supine positioning offers access to the abdomen, anterior and medial thighs, knees, calves, arms ankles, breasts, and face.

Maintaining core body temperature is best accomplished by running IV fluids through a fluid warmer in addition to the use of forced warm air by means of a Bair Hugger (Arizent Inc, Eden Paris, MN, USA). The access incisions are placed in previously marked areas using a number 11 blade and must be long enough to accommodate the fluid-infiltrating cannula. The rate of flow is controlled on the infusion pump according to the anatomic area. Generally, a wetting solution is prepared with 1 mL of epinephrine added to 1 L Ringer’s lactate at room temperature (1:1,000,000 dilution). In cases not using general anesthesia, lidocaine may be added to the wetting solution. The dose of lidocaine should not exceed 35 mg/kg, although some authors routinely use doses exceeding 50 mg/kg while maintaining a safety margin.

Treatment recommendations

Abdomen

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  3.7-mm 3-ring ultrasonic probe is used at an energy setting of 80% in VASER mode

  
  
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  Continuous mode is used for the area above the costal margin

  
  
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  Average ultrasound time is 8 to 9 minutes

  
  
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  Aspiration is accomplished with a small-diameter cannula

Optimizing outcomes

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  Apply the least amount of ultrasound energy necessary to obtain fat emulsification

  
  
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  The clinical endpoint of ultrasound application is loss of tissue resistance against the probe

  
  
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  Incision placement must be planned appropriately to facilitate access to the treatment area while avoiding torque on the ultrasonic probe

  
  
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  Small-diameter cannulae provide the greatest precision, particularly in the aspiration of superficial fat

  
  
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  Liberal use of wetting solution dispersed evenly through the fat maximizes efficiency of ultrasonic cavitation, minimizes blood loss, and provides added protection against thermal effects of UAL

  
  
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  Circumferential contouring provides a more harmonious result than local fat extraction

  
  
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  Postoperative use of foam compression garments, lymphatic drainage massage, and skin-moisturizing regimens can optimize UAL outcomes and decrease recovery times

Postoperative care

Following large-volume UAL procedures, close monitoring of fluid replacement and urine output is required. Postoperatively, most patients with large volume aspirations continue to leak fluid through the incisions for 24 to 36 hours. A significant volume of the infiltrating solution does get absorbed during the first 12 hours following major UAL and this must be considered when planning fluid replacement. Oral intake of fluids is permitted on waking. Early ambulation is encouraged, and patients are discharged on the first postoperative day. Foam and compression garments can be applied to most UAL patients in the immediate postoperative period. Lymphatic drainage and skin moisturizing regimens are helpful as soon as the patient can tolerate them.

Complications and management

The most common complications of liposuction procedures are under-extraction, over-extraction, or irregular contour. In general, these complications are prevented by the use of intraoperative flow sheets documenting infusion and aspiration volumes for each anatomic area. Under-extraction is usually corrected by revisionary extraction, whereas overcorrection may require fat grafting. Paresthesias, edema, and ecchymosis are usually self-limiting. The vibrating ultrasonic probe generates heat, which could lead to thermal injury, particularly around the incision site. The use of skin protectors is essential, along with the use of a wet towel adjacent to the incision to provide added protection. The most important factor in preventing skin burns is avoiding torque on the probes.

Seromas are the result of too much ultrasonic energy applied to the tissues either as a result of increased generator settings or prolonged application. It is seldom necessary to use energy settings greater than 80% applied for 1 to 1.5 min/100 mL of wetting solution to a particular area to achieve proper tissue fragmentation and emulsification.