(a–f) Preoperative photography for VAL contouring of the trunk
Preoperative markings are performed in the standing position. In females I usually mark the abdomen first making sure that I address both, the linea alba and linea semilunaris with my markings. Also the location of the anterior superior iliac spine is marked since creating a shadow effect in that area provides a very athletic appearance. Using the pinch test, the areas of extraperitoneal fatty deposits are mapped out. In the typical female patient undergoing VASER-assisted liposuction of the abdomen, the idea is to evacuate as much extraperitoneal fat as the skin turgor allows and to create the natural shadow effects of the anatomical landmarks without the extensive etching performed in the high-definition body sculpting discussed elsewhere in this book. In males the markings are slightly different. The midline is marked mostly above the umbilicus, the lateral edges of the rectus muscles are marked, and the suboblique triangle described by Hoyos  is also marked (Fig. 6.3). Markings of the posterior trunk are depicted in Fig. 6.4 and include the location of the back roll creases.
I typically begin circumferential contouring of the trunk with the back and flanks. There are two options for positioning the patient on the operating table and both have pros and cons. The prone position requires meticulous padding of all pressure points from bony prominences and proper protection of the face and breasts. When starting out in this position under general anesthesia, it is useful to perform the anesthesia induction and endotracheal intubation on the stretcher adjacent to the operating table and then transferring the patient directly to the table in the prone position over the hip rolls and axillary rolls. The operating table is then flexed slightly to provide better lineal access for the VAL probes and avoid torqueing them over the curved anatomical areas of the back and flanks. The prone position provides fairly good access to the back and flanks and the position makes it easier to access symmetry since the surgeon is visualizing both sides simultaneously during the surgery. Another advantage of the prone position in circumferential contouring is that it requires only one additional patient repositioning to the supine position in order to complete the abdominal areas. In spite of these advantages, many experienced body contouring surgeons, including the author, prefer contouring of the posterior trunk in the lateral decubitus position. This position also requires an axillary roll and padding of the bony prominences. Although this position for liposuction requires an additional repositioning (side-side-supine versus prone-supine), many including the author feel that the lateral decubitus position provides better access for UAL cases with less trauma. The position is extremely helpful when evacuating large volumes from the back and flanks and in the creation of small aesthetic waistlines. Once both sides of the posterior trunk are completed, the patient is then turned to the supine position for completion of the abdominal contouring.
It was once common to perform the surgical prepping for circumferential liposuction prior to induction of anesthesia. The patient in the standing position would be sprayed in a circumferential manner using povidone-iodine (Betadine) solution. The operating table would be draped with the sterile sheets and the prepped patient would lay down on the sterile sheets after which the sterile draping would be completed. This prepping and draping method has been abandoned by many including the author who now prefers to prep and drape an anesthetized patient in the surgical position on the operating table using povidone-iodine (Betadine) gel. Access incisions for abdominal VAL are typically placed in the upper pubic area (below the bikini line) on each side and in the midline. Another access incision is placed in the superior internal aspect of the umbilicus for access to the upper abdomen. The author usually performs liposuction surgery of large surface areas under general anesthesia and only small-volume aspirations under local. The “superwet” guidelines call for an approximate 1:1 ratio of fluid infiltrate to expected aspirate volume; however this is not nearly enough wetting solution for VAL surgery. In the author’s experience these cases require a minimum of 3:1 ratio of wetting solution to expected aspirate volume. The idea is to create a blanched and turgid treatment area. The high volume of fluid in the tissues during VAL cases promotes fat fragmentation and offers a measure of thermal protection. Furthermore, high-volume infiltration is associated with cleaner aspirate since the high hydrostatic pressure aids in hemostasis. For most areas of the trunk, the wetting solution is infiltrated by means of an infiltration pump at a rate of 400 ml/minute until the fluid is evenly dispersed throughout the tissues. There are a number of wetting solution formulas described in the literature [6–8]. For major VAL cases under general anesthesia, the author employs Garcia’s formula , which consists of 1 ml of epinephrine 1:1000 in 1 liter of Ringer’s lactate at room temperature. Formulas that advocate warming the wetting solution are not recommended for ultrasonic liposuction surgeries. For smaller cases under local anesthesia, 30 ml of 1% xylocaine is added to a liter of the wetting solution. At any rate, if xylocaine is used in the wetting solution, the author does exceed a total dose of 35 mg/kg even though some authors claim to use doses exceeding 50 mg/kg while maintaining a safety margin [10, 11]. Smaller surface area liposuctions performed under local do not require such high volumes of wetting solutions, and large surface area cases under general anesthesia do not require the use of xylocaine, so there is really no good reason to push the limits of lidocaine toxicity in these patients. Following the infiltration of the wetting solution, it can take approximately 15 minutes for the patient to experience the full vasoconstrictive effect of the epinephrine; however unlike aspiration cannulas, gently passing VASER ultrasound probes through the tissues is not associated with bleeding so the ultrasound delivery phase is begun immediately after the wetting solution is infused. Prior to aspirating the ultrasound treated area, the next area in line for treatment undergoes infusion of the wetting solution. Employing this infusion protocol, the author has on occasions used cumulative epinephrine doses of up to 14 mg without untoward effects.
Prior to the ultrasound phase, skin protectors are inserted into all the access incisions. A wet sponge is used behind the access incisions to protect the skin from the probes (Fig. 6.5). Currently the author uses a 3.7 mm, three-ring VASER probe (Solta Medical, Bothell, WA) for treating the flanks at 80% energy level in pulsed mode and a 3.7 mm, two-ring VASER probe for the back rolls and upper back at 80% energy level in pulsed or continuous mode. The one-ring probe is seldom if ever used by the author. The endpoint for the ultrasound phase is lack of tissue resistance to the probe. In the early days of VASER liposuction, it was suggested that most areas needed to be exposed to the ultrasound for 1 minute/100 ml of wetting solution to achieve adequate tissue fragmentation. That suggestion proved inaccurate since it has been shown that adequate tissue fragmentation occurs with far less ultrasound exposure. Other than using tissue resistance to the probe as a guideline for ultrasound times which requires some experience with the device, a useful guideline is 1 minute exposure/100 ml of expected aspirate from the area being treated. Typically my VASER ultrasound times for posterior trunk contouring range from 12 to 15 minutes. For the abdomen a 3.7 mm, five-ring probe is used at 70–80% energy level in pulsed mode. Aspiration of the emulsified fat in VAL cases is relatively easy when compared to SAL. The author uses 3.7 mm and 3.0 mm VentX atraumatic cannulas (Solta Medical, Bothell, WA) for the aspiration phase. Typical VASER aspirate from circumferential trunk contouring is relatively bloodless (Fig. 6.6).
Upon completion of the aspiration each access incision is closed with one buried 4-0 absorbable monofilament suture. Drains are not used. TopiFoam is applied over all the treated areas followed by a compression garment (Fig. 6.7a–c).
A 31-year-old female was seen in consultation regarding contouring of her trunk and extremities. Circumferential VAL of these areas was performed under general anesthesia as an outpatient procedure. Positioning included right lateral decubitus to left lateral decubitus to supine. Wetting solution consisted of 1 ml of epinephrine 1:1000/liter Ringer’s lactate solution infused at 400 ml/minute. Three liters were infused into the abdominal area and 5 liters were infused into the posterior trunk. The abdomen was treated with a 3.7 mm, five-ring VASER probe at 80% energy level for 8 minutes in pulsed mode and the posterior trunk was treated with a 3.7 mm, two-ring probe at 80% energy level for 11 minutes in continuous mode. Aspiration was performed with 4.6, 3.7, and 3.0 mm VentX cannulas. Total volume extracted was 6400 ml. Surgical results at 1 year are depicted in Fig. 6.8a–f.
A 38-year-old female patient was seen in consultation regarding improving the contours of her abdomen, flanks, and back. She has some abdominal skin irregularities and a lower abdominal contour deformity from a previous laser liposuction 3 years prior. A circumferential VAL of her trunk with lipo-shifting in the abdomen to correct the irregularities from the previous liposuction plus possible fat grafting of the lower abdominal contour deformity were the recommended procedures. The outpatient surgery was performed under general anesthesia. Positioning included right lateral decubitus to left lateral decubitus to supine. Wetting solution consisted of 1 ml of epinephrine 1:1000/ liter Ringer’s lactate solution infused at 400 ml/minute. Three liters were infused into the abdominal and pubic areas and 4 liters were infused into the posterior trunk. Treatment of the abdominal area consisted of a 3.7 mm, three-ring VASER probe in at 80% energy level for 8 minutes in pulsed mode and the posterior trunk was treated with a 3.7 mm, two-ring probe at 80% energy level in pulsed mode for the flanks and continuous mode for the back rolls. VASER exposure time for the posterior trunk was 12 minutes. Aspiration was performed with 4.6, 3.7, and 3.0 mm VentX cannulas. Total volume extracted was 6800 ml. Surgical outcomes after 6 months are depicted in Fig. 6.9a–f.
A 28-year-old athletic male was seen in consultation regarding mild lipodystrophy of his abdomen and flank areas. Due to his excellent skin tone, aggressive circumferential VAL of the abdomen and flanks was recommended. The outpatient surgery was performed under general anesthesia. Positioning included right lateral decubitus to left lateral decubitus to supine. Wetting solution consisted of 1 ml of epinephrine 1:1000 per liter of Ringer’s lactate solution infused at 400 ml/minute. Two liters were infused into the abdominal area and 2.5 liters were infused into the flanks. Treatment of the abdominal area consisted of a 3.7 mm, five-ring VASER probe at 80% energy level for 7 minutes in pulsed mode and the flanks were treated with a 3.7 mm, two-ring probe at 80% energy level for 6 minutes in pulsed mode. Aspiration was performed with 3.7 and 3.0 mm VentX cannulas. Total volume extracted was 2900 ml. Surgical results at 6 months are depicted in Fig. 6.10a–f.