Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

530
PART | 7  Liposuction and fat grafting
FIG. 48.14  Cellular and molecular events after adipose tissue grafting. Adipose grafting induces injury in the recipient tissue; bleeding from the
host tissue activates platelets, which release various soluble factors activating sleeping stem/progenitor cells. At the same time, transplanted adipose
tissue is temporarily placed under severe ischemia; basic fibroblast growth factor (bFGF) and other factors are released from injured tissue or dying
cells and stimulates adipose-derived progenitor cells to release hepatocyte growth factor (HGF), which promotes angiogenesis and inhibits fibrogenesis.
Tissue injury further induces inflammatory cell infiltration and release of inflammatory cytokines. Most of the differentiated cells in the graft die, but
graft-resident stem/progenitor cells are activated and bone marrow-derived stem/progenitor cells are recruited. The dead cells are partly replaced with
next generation cells after successful revascularization. ECM, extracellular matrix; PDGF: platelet derived growth factor; EGF, epidermal growth factor;
TGF-β, transforming growth factor-β; SDF-1, stromal derived factor-1; S1P, sphingosine-1-phosphate; IL, interleukin.
Proteinases
ECM fragments
Release
Release
Release
HGF
PDGF, EGF
TGF-β, S1P
Angiogenesis,
adipogenesis
Inhibit fibrogenesis
Inflammatory cells
IL-1,6,8
Hypoxia
Hypoglycemia
Necrosis
Apoptosis
Adipose tissue and
capillary remodelling
bFGF, TGF-β
SDF-1, EGF
ECM disruption
Dying cells
Bleeding
Platelet activation
Tissue injury
FIG. 48.15  Cellular events in ischemic adipose tissue. Severe ischemia induces adipocyte death. If it is prolonged, vascular endothelial cells (VECs)
also start to die. In contrast, adipose stem/progenitor cells can stay alive up to 72 hours even under severe conditions; during the first 72 hours, they
are even activated and try to repair the damaged tissue by their regenerative efforts such as proliferation, migration and differentiation, collaborating
with bone marrow-derived infiltrated cells.
pO2=60mmHg
<24h
Day 2
Day 3
Ischemia
(pO2=15mmHg)
Macrophage
Infiltration +
Phagocytosis
Regeneration
(angiogensis +
adipogenesis)
Adipocyte death
Inflammation
VEC death
ASC activation
Progenitor death
Stem cell death

531
Chapter | 48  Minimal scar breast augmentation using autologous fat grafting
FIG. 48.16  Histology of grafted adipose tissue at 4 weeks. A section
of adipose graft at 4 weeks stained with perilipin (alive adipocytes: green)
and Hoechst (nuclei: blue) indicated that many adipocytes are dead (per­
ilipin negative), which means they are lipid droplets (some of the dead
adipocytes are indicated by asterisks). On the other hand, small new adi­
pocytes (perilipin positive: arrows) are emerging to replace the oil drop­
lets. This remodeling was progressing very slowly; the oil droplets stayed
for a long time without scavenging or absorption and thus the adipose graft
tissue can keep its volume even during the remodeling phase. This phe­
nomenon cannot be detected by H&E staining, because it cannot discrimi­
nate alive adipocytes from dead ones.
FIG. 48.17  Summarized schema of adipocyte fate after nonvascularized adipose grafting. Animal experiments of nonvascularized adipose tissue
grafting indicated that most of the adipocytes (except for those in the most superficial layers) die within 2–7 days after adipose tissue grafting. Some
of the dead adipocytes are replaced with new adipocytes of the next generation, while others are not; in the central area of the graft, even adipose stem/
progenitor cells die and the replacement of new adipocytes fails, resulting in scar tissue formation or cyst formation with frequent calcifications in the
end. The final volume retention after adipose grafting is determined by the rate of successful replacement of adipocytes.
0d
1d
1wk
4wks
8wks
12wks
Volume
retention
Ischemic
condition
Less
ischemic
Adipocyte
Macophage
Necrosis!
Phagocytosis
Cyst formation
Fibrosis
ASC
More
ischemic
Optimization of Individual
Procedural Technique
If one of the four key procedures (liposuction, storage,
preparation, and injection) as well as preoperative care
was not properly performed, good clinical outcomes cannot
be expected. Every step has been standardized, though
the standardization is not yet completed and new techniques
or devices continue to be developed. Aspirated adipose
tissue is not vascularized and many adipocytes die every
second, so that harvested adipose tissue should be kept
cool and reinjected as quickly as possible after appropriate
preparation. Fat grafts should be distributed into the proper
tissue layers as diffusely as possible (as small aliquots) to
maximize the contact surface area of grafts.
Key Factors of Graft Materials
For preparation of adipose grafts, we believe that there are
two key factors that we should consider for a better reten­
tion rate.
● One is to improve the viable cell number per volume.
This means concentrating needed components (viable

532
PART | 7  Liposuction and fat grafting
adipocytes, ASCs, and other cellular components) and
discarding unneeded components such as water, oil
(ruptured adipocytes) and erythrocytes. This is usually
performed through centrifugation or filtration with neg­
ative pressure (Fig. 48.7). Centrifugation concentrates
cellular components and separates water and oil with
variable degrees, depending on the centrifugation force
and time.12
● The other key point is to improve the cellular quality of
the graft. This means improving (normalizing) the pro­
genitor (ASC)/adipocyte ratio; aspirated adipose tissue
has been suggested to have a lower ratio than intact
adipose tissue.5 In general, stem/progenitor cells and
activating signals are crucial factors for tissue regenera­
tion. In fat grafting, there are many signals to activate
stem/progenitor cells such as injury or bleeding, but
dying adipocytes seem to be crucial signals to induce
ASC differentiation into adipogenic lineage. If the
adipose graft did not contain enough stem/progenitor
cells, the tissue regeneration would not be efficient.
On the other hand, if only stem/progenitor cells are
transplanted, stem cells would not be either activated
or differentiated into the expected direction. So, if the
tissue is stem-cell-deficient in number, it would be
reasonable to normalize stem cell density in the tissue
by supplementing the stem/progenitor cells as per­
formed in CAL strategy (Fig. 48.2) or by reducing
the adipocyte number. Centrifugation can relatively
reduce the viable adipocyte number without losing
ASC12 (Fig. 48.7).
PRE- AND POSTOPERATIVE CARE
The skin envelope of the breasts and availability of fat in
donor sites affects the injection volume. In thin patients
with tight breast skin, implant augmentation may be recom­
mended. The implants can be replaced with adipose tissue
after 1 year; the breast skin is expanded at the time of
removal.
After the surgery, the breasts should be kept in a proper
position with appropriate taping or a proper-sized bra.
Patients can take a shower on the next day. Massage of the
breasts is prohibited, preferably for the first 3 months,
because immobilization of grafts is critical for better
volume retention.
COMPLICATIONS AND
THEIR MANAGEMENT
If the injection was performed inappropriately, problems
derived from fat necrosis would be seen, such as no
augmentation effects, cyst formation, and calcification.
Small cysts (<8 mm) detected by echogram usually disap­
pear between 6 and 18 months, so no treatment is needed.
Small calcifications may occur 1–2 years after surgery but
they are usually easy to distinguish from malignant signs.
It is important to avoid injection into the mammary glands
and to record MRI and/or mammogram before and after
surgery. Pneumothorax is possible by mechanical damage
to the pleura. A larger volume of liposuction could induce
postoperative donor site problems such as irregularity or
seroma, especially in lean patients, so that preoperative
selection of patients and careful procedures in liposuction
are needed.
CONCLUSION
Although augmentation volume is relatively limited, fat
grafting is a practical option for breast augmentation and
reconstruction because a natural contour and softness
can be obtained without incisional scars or potential risk
derived from foreign bodies. It is important to use appro­
priate techniques for each procedural step (liposuction,
graft preparation, and injection) as well as good postop­
erative care to achieve better volume retention and avoid
complications.
REFERENCES
1. Spalding KL, Arner E, Westermark PO, et al. Dynamics of fat cell
turnover in humans. Nature 2008;453:783–7.
2. Zuk PA, Zhu M, Ashjian P, et al. Human adipose tissue is a source
of multipotent stem cells. Mol Biol Cell 2002;13:4279–95.
3. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety
and efficacy. Plast Reconstr Surg 2007;119:775–85.
4. Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotransfer (CAL)
for cosmetic breast augmentation: supportive use of adipose-derived
stem/stromal cells-. Aesth Plast Surg 2008;32:48–55.
5. Matsumoto D, Sato K, Gonda K, et al. Cell-assisted lipotransfer:
supportive use of human adipose-derived cells for soft tissue aug­
mentation with lipoinjection. Tissue Eng 2006;12:3375–82.
6. Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotransfer for
facial lipoatrophy: efficacy of clinical use of adipose-derived stem
cells. Dermatol Surg 2008;34:1178–85.
7. Yoshimura K, Asano Y, Aoi N, et al. Progenitor-enriched adipose
tissue transplantation as rescue for breast implant complications.
Breast J 2010;16:169–75.
8. Yoshimura K, Suga H, Eto H. Adipose-derived stem/progenitor cells:
roles in adipose tissue remodeling and potential use for soft tissue
augmentation. Regen Med 2009;4:265–73.
9. Yoshimura K, Shigeura T, Matsumoto D, et al. Characterization
of freshly isolated and cultured cells derived from the fatty and
fluid portions of liposuction aspirates. J Cell Physiol 2006;208:
64–76.

533
Chapter | 48  Minimal scar breast augmentation using autologous fat grafting
10. Aiba-Kojima E, Tsuno NH, Inoue K, et al. Characterization of
wound drainage fluids as a source of soluble factors associated with
wound healing: comparison with platelet-rich plasma and potential
use in cell culture. Wound Repair Regen 2007;15:511–20.
11. Suga H, Eto H, Aoi N, et al. Adipose tissue remodeling under isch­
emia: Death of adipocytes and activation of stem/progenitor cells.
Plast Reconstr Surg 2010;126:1911–23.
12. Kurita M, Matsumoto D, Shigeura T, et al. Influences of centrifuga­
tion on cells and tissues in liposuction aspirates: optimized centrifu­
gation for lipotransfer and cell isolation. Plast Reconstr Surg
2008;121:1033–41.

534
© 2013 Elsevier Inc
Chapter 49 
Key Points
●
Use in patients who have mild to moderate skin laxity.
●
Use in patients with mild to moderate adipose volume.
●
Small 1 mm fiber can address defects close to skin
surface.
●
Useful for areas with previous scar tissue or previous
fat grafts.
●
Laser heat energy very measureable and controllable.
Principles of new invasive modalities
Barry E. DiBernardo and Jason N. Pozner
A.  LASER-ASSISTED LIPOSUCTION
INTRODUCTION
Liposuction is considered the gold standard procedure for
body sculpting and contouring.1 The introduction of the
tumescent technique has reduced the risk of bleeding,
reducing the need for general anesthesia and hospitaliza­
tion, and diminished postoperative ecchymoses associated
with liposuction.1–5 Other advances include the refinement
of body site-specific cannulas and the use of manual syringe
suction for autologous fat transfer and fine contouring.6
More recently, ultrasound-assisted liposuction (UAL),
power-assisted liposuction (PAL), vibroliposuction, and
laser-assisted liposuction have shown promise in facilitat­
ing fat removal and in reducing procedure duration, surgeon
strain, patient recovery time, and postoperative pain.1,4,5,6
A detailed study7 described the physics, quantification
and safety of subdermal laser heat treatment. Later, the
same authors presented a preliminary report on skin shrink­
age and increased elasticity as a result of multi-wavelength
laser application.8 Although the aforementioned study
showed promising results, it did not directly compare the
effects of laser-assisted liposuction to those of an internally
controlled traditional liposuction alone. A subsequent study
obtained quantitative, objective data for comparing tissue
shrinkage and skin tightening achieved by laser-assisted
liposuction vs. liposuction alone. Skin shrinkage was quan­
tified by changes in surface area and skin tightening was
quantified by changes in the skin stiffness index.9 This led
to the proof of the unique significance of laser energy appli­
cation; the first concurrent method to definitively address
skin laxity in the body contouring patient without the need
for invasive excision intervention.
PREOPERATIVE PREPARATION
Patients are consulted in terms of fat reduction and skin
laxity improvement. Since specific areas are treated, patients
are marked for the usual fat attention in addition to 5×5 cm
squares representing the areas of skin laxity energy applica­
tion (Fig. 49.1). Tumescent fluid, approximately 50–100 ml
per 5×5 cm2 sector, is administered. In addition, patients are
given two oral Valium (10 mg each) and two Percocet®
(acetominophen 325 mg/hydrocodone 5 mg) approxi­
mately 20–30 minutes prior to tumescent fluid application
(Fig. 49.1). The procedure is rarely done with more than
oral and local anesthesia.
The surgical plan is for a biplanar technique to disrupt
adipose cells, resulting in a more liquefied material that can
be removed through a smaller cannula. This refines the
removal, especially closer to the surface, reducing contour
irregularity from larger instrumentation. Surface tempera­
ture goals of 40–42°C, if measured superficially, or 47–
52°C, if measured deep, are used for increased skin elasticity
and tightening. This is the most important aspect of
this procedure for managing patient expectations and dili­
gence in achieving these temperature goals, uniformly, is
of utmost importance. It is also necessary to stress to
the patient that the skin tightening goal is a function of
their age, genetics and skin condition from environmental
factors such as smoking and sun. If expectations for
outcomes are in terms of a surgical procedure, then that
should be performed. For optimizing outcomes, please see
Box 49.1.
For additional online content visit

Part 7  Liposuction and fat grafting

535
Chapter | 49  Principles of new invasive modalities
FIG. 49.1  Application of tumescent fluid 50–100 ml per sector.
BOX 49.1  Optimizing Outcomes:
Laser-Assisted Liposuction
●
Limit the size of the procedure to 24 sectors: Proper
energy delivery takes time (5 min per sector) for the
whole procedure.
●
Do not give insufficient energy to potentially reduce skin
tightening.
●
Heat causes swelling for the first 4 weeks. Any areas
of dense swelling or firmness need to be treated
with massage or mechanical interventional devices if
available.
●
Good patient selection.
●
Indicate to patient that the skin component takes at least
90 days to take effect.
●
Avoid the nerves of the face; neck below mandible is
fine.
●
Treat mild to moderate fat volumes.
●
Avoid hanging skin in lieu of surgery.
●
Best areas are neck, brachial, lower abdomen, medial
thigh, and back rolls.
SURGICAL TECHNIQUE
The laser system used (Triplex®, Cynosure, Westford, MA,
USA) permits 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 or 1000 µm
fiber threaded through a 1 mm microcannula and extending
2 to 3 mm beyond the distal end of the microcannula. When
the microcannula is inserted in tissue, the laser is activated
and the microcannula is moved slowly and evenly through
the deep fat layer with a 1064–1440 nm combination (Fig.
49.2), or the superficial subdermal layer with a 1064–
1320 nm combination. Wavelength combinations are used
for preferential target affinity of fat (deep) and water (dermis),
respectively, for ideal absorption and performance.
Patient safety is addressed with respect to energy deliv­
ery via an accelerometer delivery system (Smart Sense®,
Cynosure) attached to the laser handpiece, used to mini­
mize the occurrence of localized thermal damage during
treatment, If, during treatment, the surgeon slows the
motion of the handpiece, the laser power delivered drops
accordingly. If the handpiece stops, energy delivery ceases
within 0.2 s. Temperature safety is measured with a therm­
istor probe at the tip of the cannula, which is then set for
a safe range measured below the skin, usually 47–52°C
(Fig. 49.3).
FIG 49.3 APPEARS ONLINE ONLY
The laser will stop firing when this threshold is reached,
again adding to the safety of the system. Although at this
point the thermistor is fully capable of measuring tempera­
ture throughout all levels of the procedure, previous surface
measurements were taken with a laser-guided thermometer,
needing an additional assistant to operate it (Fig. 49.3). The
accuracy of these devices was confirmed in studies using a
thermal camera (Fig. 49.4).
FIG 49.4 APPEARS ONLINE ONLY
The tissue is treated using a two-layer/two-step tech­
nique. The first step is to treat the deep fat layers (1–3 cm
below the epidermis) within the premarked squares (Fig.
49.2). Two to four incisions, 1 mm each, are made with a
number 11 blade in each treated area, for insertion of the
microcannula. Subsequently, in the second step, the super­
ficial subdermal layer (0.5 cm below the epidermis) is
treated (Fig. 49.5). The entire surgically marked site(s) are
then aspirated with a standard 3 mm suction cannula to
remove any remaining fat, disrupted cells, and free fat oils.
Patient examples are seen in Figs 49.6–49.8, after
waiting at least 90 days to see any improvement in skin
elasticity and firmness after controlled laser heat stimula­
tion of fibroblasts.
Avoidance of mistakes in this procedure is centered on
complete delivery of energy and safety controls. Inadequate
tightening can often be seen due to a temperature threshold
insufficient to achieve an effect (usually seen over 90 days).
Complications relevant to adding laser energy to the proce­
dure are from heat buildup in the deep planes leading to fat
necrosis (firmness), or in the superficial planes causing
skin blistering, burns or pigmentation changes.10 Optimal
aforementioned safety mechanisms are in place to avoid
such uncontrolled temperatures in most instances, if used
properly.
POSTOPERATIVE CARE
When aspiration is complete, standard firm pressure dress­
ings are applied to the wounds and subjects are instructed
to wear a compression garment for the following 3–4

535.e1
Chapter | 49  Principles of new invasive modalities
FIG. 49.3  Example of simultaneous surface measurement with
laser-guided thermometer and deep measurement with thermistor at
cannula tip.
FIG. 49.4  Thermal camera temperature measurement used in
studies to verify safety parameters.

536
PART | 7  Liposuction and fat grafting
FIG. 49.2  Diagrammatic representation of placement of deep laser energy for adipocyte and fibrous disruption.
Epidermis
Dermis
Subcutaneous Tissue
FIG. 49.5  Superficial laser application just under the dermis, with
visualization of helium neon guiding beam.
weeks. Oral antibiotic prophylaxis is given. Dependent
incisions are left open for drainage.
Patients are usually seen at one week to check skin and
tissue firmness. If there is excessive swelling or dense
edema, intervention is started with the use of the Triactive
Device (Cynosure), or equivalent massage, edema reduc­
tion and lymphatic drainage enhancement for the next 3
weeks. Patients are reminded of the time necessary for skin
changes due to fibroblast stimulation (90 days). If, after 3
months, further enhancement of skin is desired, acceptable
external skin devices can be applied. Additional treatments
in adjacent areas can be performed after 3 months or when
tissue effects have subsided.
COMPLICATIONS AND
THEIR MANAGEMENT
Detailed and comprehensive accounts of the identification
and management of laser device complications are beyond

537
Chapter | 49  Principles of new invasive modalities
FIG. 49.7  Clinical example of brachial fat removal and skin tightening from laser. Preoperative (A) and 3 months postoperative (B).
A
B
the scope of this chapter. These include the following: blis­
ters, end hits, burns, blow holes, prolonged edema, heat/
pressure problems, neuropraxia, permanent nerve damage,
contour irregularity, and insufficient effect.10 Although this
is a complete list, their occurrence is very low if performed
properly.
CONCLUSION
The use of laser-assisted liposuction has increased in clini­
cal practice. Previous work has confirmed the safety,
efficacy and temperature parameters to elicit skin tighten­
ing. In the right candidates, laser has been proven to be a
reliable and controllable source to address fat and skin in
a safe environment. Future applications of fiber deliverable
energy will be used to attack defects in the superficial
aspect of the skin such as dimpling, scars and, of course,
cellulite.11
B.  CRYOLIPOLYSIS
INTRODUCTION
Cryolipolysis is a noninvasive procedure that uses precisely
controlled cooling to target and eliminate adipocytes
without damage to surrounding tissues.12 Cryolipolysis is
FIG. 49.6  Clinical example of back rolls. Preoperative (A) and 3 months postoperative (B).
A
B

538
PART | 7  Liposuction and fat grafting
FIG. 49.8  (A, B) Clinical example of neck treatment in a 48-year-old patient, 3 months postoperative. Note slight muscle bands evident.
A
B
FIG. 49.9  Assessing a patient’s fat using a C-shaped cup
technique.
performed using the Zeltiq Breeze System® as part of the
CoolSculpting™ procedure (Zeltiq Aesthetics, Pleasanton,
CA).
Adipocytes respond differently to cooling than other
cell types. Precisely controlled cooling causes lipid crystal­
lization and triggers apoptosis in adipocytes, while in non-
lipid-storing cells, lipids are left undamaged. Lipids released
by apoptotic fat cells are removed gradually through the
lymphatic system, reducing tissue volume.12,13
PREPROCEDURE PREPARATION
To assess a patient’s fat, the patient should be standing so
the fat is subject to gravity. By mimicking the applicator
opening using a C-shaped cup technique (Fig. 49.9), the
clinician can assess how much fat will be drawn into the
applicator cup. A minimum of 2.5 cm of fat should be
drawn into the cup for best results.
Before treatment, using templates provided by Zeltiq,
the clinician should mark the center point of each
bulge with an X. For a continuous section of fat, several
placements may be required, ideally with a slight
overlap.
A gelpad provides thermal contact between the patient’s
skin and the applicator. It should be placed over the center
of the treatment site. The applicator should be placed
directly on the gelpad over the X. It is critical that the
gelpad extend beyond the edges of the panels in the applica­
tor cup (Fig. 49.10).

539
Chapter | 49  Principles of new invasive modalities
TECHNIQUE
The treatment profile is chosen from the instrument’s touch
screen. Some profiles include a short massage session,
which enhances the selective injury to the adipocytes.
Once the applicator is properly placed and the patient is
comfortably positioned, the clinician can start the cooling
FIG. 49.11  Before (A) and 2 months after (B) CoolSculpting™ – front view.
A
B
FIG. 49.10  Proper placement of the gelpad and applicator on a
patient.
cycle. The instrument uses vacuum pressure to draw the
tissue into the applicator for optimal cooling.
OPTIMIZING OUTCOMES
Patient selection is critical for optimal outcomes. Patients
should be at or near their ideal body weight and have good
skin tone with minimal laxity for best results. Ideal patients
have pockets of fat with distinct borders, that are resistant
to diet and exercise.
Patients typically see a 20% reduction in the thickness
of the fat layer with each treatment14 (Figs 49.11 and 49.12).
Results are visible with a single procedure, but multiple
procedures may be recommended, depending on the
patient’s esthetic goals.
FIG 49.12 APPEARS ONLINE ONLY
Results may be observed as early as 3 weeks post-
treatment, but full results are visible in 2–4 months.
POSTPROCEDURE CARE
Postprocedure, the treated tissue may appear red and raised
and may be cold and firm. These changes resolve within a

539.e1
Chapter | 49  Principles of new invasive modalities
FIG. 49.12  Before (A) and 2 months after (B) CoolSculpting™ – profile view.
A
B

540
PART | 7  Liposuction and fat grafting
generation of devices are used on the abdomen and flanks
and legs. The size of the transducer prohibits treatment of
smaller areas like arms.
Before treatment, the clinician should mark the outline
of the area to be treated. The Ultrashape® system comes
with a disposable drape kit with tracking circles. These are
arranged around the area to be treated and the device's
tracking system is linked to the transducer handpiece.
TECHNIQUE
The operator places a transducer on the skin, which has been
lubricated with oil to enhance conduction. The operator
follows a pattern on the device screen which makes sure that
the area is treated evenly with no overlap. The device dwells
for 1 second per area and delivers the ultrasonic energy.
FIG. 49.13  Ultrashape® device.
few minutes to a few hours. Bruising, soreness, tenderness,
cramping, and tingling may occur, but usually resolve
within a few days to a few weeks.15
COMPLICATIONS AND
THEIR MANAGEMENT
In rare instances some patients may experience significant
pain after treatment. This side effect occurs in very few
cases and usually resolves within 2–3 weeks.15
CONCLUSION
Cryolipolysis is an effective option for patients who want
a noninvasive procedure to reduce fat in bulges, rolls, or
other small areas that are resistant to diet and exercise.
Cryolipolysis does not have an effect on tightening collagen
within the skin or deeper layers.
C.  EXTERNAL ULTRASONIC DEVICES
INTRODUCTION
Focused ultrasound has been used in medicine for quite
some time. Current devices from a number of companies
use focused sound waves in a noninvasive procedure to
target and eliminate adipocytes without excessive damage
to surrounding tissues.16
These devices have ushered in a new era in plastic
surgery – nonsurgical devices that specifically target fat and
that have minimal to no pain, no downtime, and minimal
to no risk. The most well known devices in this category
are Ultrashape® (Yokneum, Israel) (Fig. 49.13) and Lipo­
sonix® (Solta Medical, Hayward, CA).
These devices differ in the frequency of the ultrasound
waves used to target fat. The Ultrashape® device operates
at 0.2 MHz and is thought to act by creating a cavitative
effect within the adipocytes. The Liposonix® device oper­
ates at 2 MHz and is thought to act with a thermal mecha­
nism, destroying the adipocytes through heat. In both
procedures, lipids released by ablated fat cells are removed
gradually through the lymphatic system, reducing tissue
volume. Ultrashape® is discussed in this section and Lipo­
sonix® is discussed in another chapter.
Both Ultrashape® and Liposonix® are not approved by
the FDA for use in the United States at this time (January
2011).
PREPROCEDURE PREPARATION
To assess a patient’s fat, the patient should be standing so
the fat is subject to gravity. The clinician needs to assess
the fat thickness, as a minimum of 1.5 cm of fat is generally
needed for efficacy, although advances in the technologies
may allow thinner subjects to be treated. The current

541
Chapter | 49  Principles of new invasive modalities
After the pulse the operator moves the transducer to the next
spot that is marked on the screen. The tracking system keeps
track of the area treated so as not to re-treat, although some
are experimenting with two passes per session.
Newer versions of this device have a radiofrequency
head which may be used before and after treatment to
help prepare and mobilize the fat. The usual treatment
protocol is for three sessions, 2 weeks apart, with radiofre­
quency treatments at the same time and during the untreated
weeks.
OPTIMIZING OUTCOMES
Patients need to understand that these devices are less effi­
cacious than liposuction. Almost all patients will see results
but some more than others. Results may be observed as
early as 3 weeks post-treatment, but full results are visible
in 2–4 months (Figs 49.14 and 49.15). Work is being done
to determine who will be the best responders.
FIG 49.15 APPEARS ONLINE ONLY
POSTPROCEDURE CARE
No postprocedure care is necessary and patients may
resume all activities immediately. Postprocedure, the treated
tissue may be slightly bruised and swelling may occur.
These changes resolve within a few days. Sensory changes
may also occur but usually resolve within a few days to a
few weeks.
COMPLICATIONS AND
THEIR MANAGEMENT
In rare cases a burn may occur with treatment. This side
effect is extremely rare.
CONCLUSION
Focused ultrasound is an effective option for patients who
want a noninvasive procedure to reduce fat in bulges, rolls,
or other small areas that are resistant to diet and exercise.
FIG. 49.14  Before (A) and after (B) three Ultrashape® sessions. (Courtesy of Dr. Hector Leal-Silva Monterrey, Mexico.)
A
B

541.e1
Chapter | 49  Principles of new invasive modalities
FIG. 49.15  Before (A) and after (B) three Ultrashape® sessions. (Courtesy of Dr. Hector Leal-Silva Monterrey, Mexico.)
A
B

542
PART | 7  Liposuction and fat grafting
REFERENCES
1. Parlette EC, Kaminer ME. Laser-assisted liposuction: here’s the
skinny. Semin Cutan Med Surg 2008;27(4):259–63.
2. Klein JA. Anesthesia for liposuction in dermatologic surgery. J Der­
matol Surg Oncol 1988;14:1124–32.
3. Klein JA. Tumescent technique for local anasthesia improves safety
in large-volume liposuction. Plast Reconstr Surg 1993;92:1085–98
discussion 1099–1100.
4. Heymans O, Castus P, Grandjean FX, et al. Liposuction: Review of
the techniques, innovations, and applications. Acta Chir Belg
2006;106:647–53.
5. Goldman A, Gotkin RH. Laser-assisted liposuction. Clin Plast Surg
2009;36(2):241–53, vii; discussion 255–260.
6. Mann MW, Palm MD, Sengelmann RD. New advances in liposuc­
tion technology. Semin Cutan Med Surg 2008;27(1):72–82.
7. DiBernardo BE, Reyes J, Chen B. Evaluation of tissue thermal
effects from 1064/1320-nm laser-assisted lipolysis and their clinical
implications. J Cosm Laser Ther 2009;11(2):62–9.
8. DiBernardo BE, Reyes J. Evaluation of skin tightening after
laser assisted liposuction: preliminary report. Aesth Surg J 2009;29:
400–7.
9. DiBernardo BE. Randomized blinded split abdomen study evaluat­
ing skin shrinkage and skin tightening in laser-assisted liposuction
versus liposuction control. Aesth Surg J 2010;30(4):593–602.
10. DiBernardo BE. Recognition and management of complications
of fat and cellulite treatments. In: Katz BK, Saddick NS, editors.
Recognition and Management of Complications of Fat and Cellulite
Treatments in Body Contouring. Philadelphia: Elsevier Saunders;
2010. Chapter 16, p. 183–92.
11. DiBernardo BE. Treatment of cellulite with 1-year follow-up using
a 1440-nm pulsed laser: preliminary report. Aesth Surg J 2011;31(3):
328–43.
12. Manstein D, Laubach H, Watanabe K, et al. Selective cryolysis: a
novel method of non-invasive fat removal. Lasers Surg Med 2008;
40:595–604.
Fig. 49.3, Fig. 49.4, Fig. 49.12, Fig. 49.15 can be found online.
Bonus images for this chapter can be found online at

13. Zelickson B, Egbert BM, Preciado J, et al. Cryolipolysis for nonin­
vasive fat cell destruction: initial results from a pig model. Dermatol
Surg 2009;35:1462–70.
14. Rosales-Berber I, Diliz-Perez ES, Allison J. Accumulative abdomen
fat layer reduction from multiple Zeltiq cryolipolysis procedures.
Phoenix, Arizona: American Society for Laser Medicine and Surgery
2010 Annual Meeting, Abstract 501; April 16–8, 2010.
15. Burns AJ, Allison J, Bachelor E, et al. Analysis of side effects of
noninvasive cryolipolysis for subcutaneous fat layer reduction –
interim report from controlled clinical trials. Phoenix, Arizona:
American Society for Laser Medicine and Surgery 2010 Annual
Meeting, Abstract 63; April 16–8, 2010.
16. DiBernardo, BE, Pozner, JN. Lasers and Non-surgical Rejuvenation.
Philadelphia: Saunders; 2009.
FURTHER READING
Ascher B. Safety and efficacy of ultrashape contouring treatments to
improve the appearance of body contours: multiple treatments in
shorter intervals. Aesth Surg J 2010;30(2):217–24.
Brown SA, Greenbaum L, Shtukmaster S, et al. Characterization of non-
thermal focused ultrasound for non-invasive selective fat cell disrup­
tion (lysis): technical and pre-clinical assessment. Plast Reconstr Surg
2009;124:92–101.
Moreno-Moraga J, Valero-Alte’s T. Body contouring by non-invasive
transdermal focused ultrasound. Lasers Surg Med 2007;39:315–23.
Teitelbaum S, Burns J, Kubota J, et al. Non-invasive body contouring by
focused ultrasound: safety and efficacy of the Contour 1 device in
a multi-center, controlled clinical study. Plast Reconstr Surg 2007;
120(3):779–89.

543
© 2013 Elsevier Inc
Chapter 50 
Key Points
●
Be familiar with the UAL endpoint (loss of tissue
resistance against the ultrasonic probe).
●
Planning incision placement that provides direct linear
access to the treatment area is of paramount
importance to avoid placing torque on the ultrasonic
probes.
●
Use the generator energy setting and ultrasonic probe
combination that will efficiently emulsify fat in a given
area while delivering the lowest amount of ultrasound
energy to the tissues.
●
Aspirate harvested by means of third generation UAL
contains viable fat cells and is highly suitable for fat
grafting.
●
Even dispersion of the wetting solution throughout the
tissues is essential in UAL. Infusion volumes greater
than the 1 : 1 ratio suggested for superwet SAL are
frequently required for efficient UAL induced
cavitation.
Ultrasonic liposuction
Onelio Garcia Jr.
INTRODUCTION
Historical Perspective
Over 300 000 liposuction surgeries were reported in the
United States last year, making it the most common esthetic
surgical procedure performed in 2011.1 Currently only 20%
of these cases are ultrasound-assisted liposuctions (UAL)
and this percentage has remained relatively unchanged
during the past 9 years in spite of the recent advances in
the safety and efficacy of the third generation ultrasonic
liposuction devices.
Ultrasonic energy has been in use in dental and surgical
instrumentation since the late 1950s. However, it was first
applied to the field of body contouring surgery in the late
1980s, first by Scuderi2 and afterwards popularized by
Zocchi,3,4 who introduced the technique to the United States
in 1993.5 Approximately 2 years later the UAL task force
was created in response to an increase in American interest
in this new liposuction technology.6 The task force was
composed of representatives from the American Society of
Plastic and Reconstructive Surgeons, American Society for
Aesthetic Plastic Surgery, Lipoplasty Society of North
America, Aesthetic Surgery Education and Research Foun­
dation and Plastic Surgery Educational Foundation, who
collaborated with the Food and Drug Administration as
well as the manufacturers of the UAL devices. The mission
of the task force was to evaluate the safety and efficacy of
UAL in body contouring, establish appropriate indications
for its use and design the educational protocols necessary
to train plastic surgeons in the United States in the use of
UAL. By 1997 the safety and efficacy of UAL had been
established by the task force and attention was then focused
on surgical training. By 1997 comprehensive teaching
courses in UAL that included practical, hands-on training,
were offered under the direction and guidance of the UAL
task force. Over 2000 plastic surgeons were trained in UAL
techniques during the first two years that the courses were
offered.7
The original UAL device was manufactured in Italy by
the SMEI Company. It is often referred to as the first-
generation UAL device and it involved the use of solid
probes with a frequency of 20 kHz. It was a relatively slow
device taking 10 to 12 minutes to obtain 250 to 300 ml of
fat reduction.8
In the mid 1990s the second generation UAL devices
were developed and sold in the United States. The two
devices in this category consisted of the Mentor Contour
Genesis (Mentor Corp., Santa Barbara, CA) (Fig. 50.1),
which operated at a frequency of 27 kHz and the Lysonix
2000 (Lysonix Inc., Carpinteria,CA) (Fig. 50.2) with an
operating frequency of 22.5 kHz. In 1999, Chang and
Commons9 published their experience comparing these two
UAL devices in over 200 patients over a 2 year period and
found both systems to be effective.
FIG 50.1, 50.2 APPEARS ONLINE ONLY
In 2001, a third generation UAL device was introduced.
The VASER system (Sound Surgical Technologies,
For additional online content visit

Part 7  Liposuction and fat grafting

543.e1
Chapter | 50  Ultrasonic liposuction
FIG. 50.2  Lysonix 2000. Courtesy of Lysonix Inc., Carpinteria CA.
FIG. 50.1  Mentor Contour Genesis. Courtesy of Mentor Corp., Santa
Barbara, CA, reproduced with permission.

544
PART | 7  Liposuction and fat grafting
with second generation UAL technology currently remains
available but, its use appears to be declining, leaving the
third generation VASER as the most commonly used UAL
technology at the present time. In 2002, Jewell et al11 pub­
lished a multicentric, pilot clinical study using VASER-
assisted lipoplasty (VAL) and reported good results without
complications in 77 patients. The author12 reported signifi­
cantly lower quantities of blood in VAL aspirate in com­
parison to SAL aspirate in 57 patients undergoing contouring
of the posterior trunk (Fig. 50.6). A decrease in complica­
tions with third generation VAL when compared to early
UAL technology was reported by de Souza Pinto.13 Cur­
rently, for these reasons, VAL appears to be supplanting
UAL.
FIG 50.6 APPEARS ONLINE ONLY
BASIC PHYSICS OF ULTRASONIC
LIPOSUCTION
Sound is a vibratory form of mechanical energy which
travels in waves, with peaks (compression) and troughs
(rarefraction) (Fig. 50.7). Compression pushes tissue par­
ticles together and rarefraction pulls them apart. It is this
alternating nature of sound waves that causes tissue parti­
cles to vibrate in place when exposed to ultrasound. Sound
waves are measured by their frequency in Hertz (Hz). Ultra­
sound waves vibrate at frequencies higher than the sound
detection limits of human hearing which is estimated to be
about 18 kHz. Sound waves travel through media at speeds
directly proportional to the density of the medium. For
example, sound waves travel faster through bone and sig­
nificantly slower through fat. Sound wave induced tissue
fragmentation is inversely proportional to tissue density;
thus fatty tissue fragments more readily in response to ultra­
sound energy than muscle or bone.
FIG 50.7 APPEARS ONLINE ONLY
The UAL hand piece is designed to convert electrical
energy into vibratory energy. Current UAL devices achieve
this by means of piezoelectric crystals contained within the
hand piece which expand and contract when exposed to
alternating electrical current, thus producing vibrations.
These vibrations are passed from the hand piece to the
attached ultrasonic probe, which in turn vibrates in reso­
nance with the hand piece. This longitudinal back and
forth vibration occurs at the tip where third generation
ultrasonic probes have an excursion of approximately
100 µm. Advances in ultrasonic probe design currently
allow the third generation UAL devices to fragment fatty
tissue at twice the efficiency rate of the earlier generation
devices while decreasing the energy delivered to the tissues
to approximately one half.14 In addition to the generator
energy setting, the type of ultrasonic probe used determines
Louisville, CO) was named for vibration amplification of
sound energy at resonance. This new device design dimin­
ished the amount of ultrasound energy delivered to the
tissues, which had been implicated as the cause of many of
the complications reported with the earlier UAL devices.10
The VASER system (Fig. 50.3) operates at a frequency of
36 kHz and is capable of emulsifying fat rapidly while
delivering lower amounts of energy to the tissues. The
system uses a smaller diameter solid probe design with
grooves proximal to the tip (Fig. 50.4). These probes can
significantly diminish the energy delivered to the tissues,
particularly when coupled with the “VASER mode” pulsed
energy delivery system. VentX suction cannulae (Sound
Surgical Technologies, Louisville, CO) are an integral com­
ponent of the system (Fig. 50.5).
FIG. 50.3 APPEARS ONLINE ONLY
The first generation devices and the Mentor Contour
Genesis are no longer on the market. The Lysonix device
FIG. 50.4  VASER ultrasonic probes. Courtesy of Sound Surgical Tech­
nologies, Louisville, CO.
FIG. 50.5  VentX aspiration cannulae. Courtesy of Sound Surgical
Technologies, Louisville, CO.

544.e1
Chapter | 50  Ultrasonic liposuction
FIG. 50.3  VASER system. Courtesy of Sound Surgical Technologies,
Louisville, CO.

544.e2
PART | 7  Liposuction and fat grafting
FIG. 50.6  VAL aspirate contains significantly less blood and is more consistent than SAL aspirate, displaying less dispersion of both (A)
hematocrit and (B) hemoglobin values.
0
1
2
3
4
5
6
7
8
Patients
Hematocrit %
1
3
5
7
9
11 13 15 17 19 21 23 25 27 29
A
0
1
2
3
4
Patients
Haemoglobin g/dl
B
1
3
5
7
9
11 13 15 17 19 21 23 25 27 29
Vaser
Traditional
Vaser
Traditional
FIG. 50.7  Cycle of compression and rarefaction in an ultrasonic wave.
1 full cycle
Period = 1/frequency
Trough
Amplitude
Increasing
compression
Increasing
rarefaction
Peak
Time

545
Chapter | 50  Ultrasonic liposuction
10 µm are lodged within the fat tissue matrix (Fig. 50.9).
Under the effects of ultrasound these microbubbles increase
in size to 180 µm, at which point they implode and collapse
(Fig. 50.10). This process separates fat cells within the fat
tissue matrix (Fig. 50.11), which subsequently mix with the
tumescent solution by means of acoustic streaming to create
the emulsion (Fig. 50.12). Earlier theories regarding cavita­
tion induced by UAL devices described an “implosion of
the fat cell” with loss of cell membrane integrity and release
of cellular contents. Current theories on UAL induced cavi­
tation do not support the fat cell implosion theory.
how the energy is delivered to the tissues (Table 50.1).
Selecting the proper combination for a given anatomical
area allows the surgeon to apply the lowest amount of
energy necessary to emulsify fat.
Ultrasound has three basic mechanisms by which it
interacts with tissue: (1) thermal, (2) mechanical, and (3)
cavitation. The thermal effect stems from the fact that
rapidly vibrating ultrasonic probes generate heat. Although
some thermal energy is passed on to the tissues, the net
amount is relatively modest when there is good tissue dis­
persion of infiltrating solution, appropriate energy settings
and proper movement of the ultrasonic probe within the
tissues. Cimino15 has reported on the tissue thermal effects
of ultrasonic devices. The mechanical effect is created
when the rapidly vibrating tip of the ultrasonic probe con­
tacts tissue. Although this effect has been well described by
Cimino and Bond,16 it appears to play a minor role in fat
emulsification when using the third generation devices.
Cavitation is the tissue interaction most responsible for
causing fat emulsification with the current UAL devices.
When the wetting solution is dispersed within the tissues
(Fig. 50.8), small microbubbles of approximately 5 to
TABLE 50.1  Comparison of VASER Types
Probe
Energy Front
Energy Side
Type of Tissue
3.7–0
100%
0
Very fibrous
3.7–1
65%
35%
Fibrous
3.7–2
55%
45%
Moderate
3.7–3
42%
58%
Soft
FIG. 50.8  The infusion cannula dispersing the wetting solution
under pressure within the subcutaneous tissue.
FIG. 50.11  The growth of the microbubbles to almost 200 µm forces
the fat cells apart. As the microbubbles reach resonant size and col­
lapse they dislodge fat cells from the tissue matrix.
FIG. 50.12  Acoustic streaming is the result of powerful fluid forces
that create intense swirling around the vibrating ultrasonic probe tip.
This swirling causes the fat cells that have been dislodged from the
matrix to mix with the infusion fluid creating the emulsion.

546
PART | 7  Liposuction and fat grafting
“tissue selectivity” of the third generation UAL devices
(Fig. 50.15).
FIG 50.9, 50.10, 50.13, 50.14 APPEARS ONLINE ONLY
PREOPERATIVE PREPARATION
Patient selection has always been of paramount importance
in liposuction.19 During the early days of SAL, plastic sur­
geons soon learned that strict patient selection was essential
in order to consistently achieve better esthetic results with
fewer complications. This practice involved limiting the
procedure to young, healthy patients with good skin tone,
who were close to their ideal body weight and had well
defined, localized areas of lipodystrophy.20 With the advent
of wetting solutions, superficial liposuction techniques,
UAL and currently VAL, plastic surgeons have been able
to significantly expand the patient selection criteria for
Cavitation occurs in the gas microbubbles not in the fat
cells. Stable cavitation requires the gas containing micro­
bubbles in the infiltrating solution. Fat cells do not contain
gas, are not subject to ultrasonic induced cavitation and
their cellular membranes are not disrupted during the
cavitation process, as depicted in electron microscopy of
third generation UAL aspirate (Fig. 50.13A, B, C). This
explains why third generation UAL aspirate has been
described as highly suitable for fat grafting,17 since it con­
tains viable fat cells within the emulsion.18 Whereas fat
harvested by SAL may contain fat lobules of approximately
50 or more cells (Fig. 50.14), the VAL harvested emulsion
is comprised of smaller two to three viable fat cell clusters
mixed with the tumescent solution. The loose nature of
the fat matrix allows the microbubbles to easily intersperse
within the fat cells for cavitation to occur, in contrast to
the denser cellular structure of blood vessels, nerves and
muscle tissue. This phenomenon forms the basis for the
Tissue remodeling
Superficial fat treatment
Pre-treatment
Superficial
Intermediate
Deep
Normal
Selective fatty
tissue emulsification
Intermediate and
deep fat treatment
Elastic retraction
FIG. 50.15  The loose makeup of the fat tissue matrix allows modern UAL devices to specifically target only fat for fragmentation and emul­
sification. This is the basis for the high “tissue selectivity” associated with the third generation UAL devices.

546.e1
Chapter | 50  Ultrasonic liposuction
FIG. 50.9  Fat cells surrounded by wetting solution. This fluid con­
tains gas microbubbles that are 5–10 µm in size.
200
Bubble diameter in microns
Bubble origin
Bubble collapse
Bubble at
resonant size
(180 microns)
Frequency 36,00 Hz
Compression
Rarefaction
150
100
50
0
0
27.8
55.6
83.3
111.1
Time in microseconds (µs)
138.9
166.7
194.4
222.2
250
FIG. 50.10  The compression and rarefaction created by the ultrasonic energy cause growth of the microbubbles to about 20× their original
size before they collapse.

546.e2
PART | 7  Liposuction and fat grafting
FIG. 50.13  Electron microscopy of VASER harvested fat. (A) Preoperative junction of 3 adipocytes with intact cell membranes. (B) The intercel­
lular space increases as a result of ultrasound energy. The arrows point to intact cell membranes. (C) The cells are separated from each other as a result
of cavitation with their cell membranes still intact.
A
B
C

546.e3
Chapter | 50  Ultrasonic liposuction
FIG. 50.14  The fat tissue matrix is composed of fat pearls which in
turn are composed of several fat lobules which contain 50 or more fat
cells (adipocytes).
Fat section
Fat pearl
Fat lobule
Fat cells
(adipocytes)

547
Chapter | 50  Ultrasonic liposuction
undergoing liposuction, with approximately 25% of the
deaths being the result of PE. In the author’s experience,
the proper use of intermittent pneumatic compression boots
coupled with early ambulation is associated with virtually
zero DVT related complications in liposuction procedures.
The protocol for patients at high risk for DVT during exci­
sional body contouring procedures should include prophy­
lactic doses of low molecular weight heparin (LMWH).
Most surgeons do not use pharmacological DVT prophy­
laxis for routine liposuction procedures because of the com­
plications related to excessive bleeding/bruising during the
procedure.
Using a preoperative data sheet with body diagrams is
helpful in documenting the specific areas selected for con­
touring, presence of asymmetries, contour irregularities,
dimpling, skin tone, and scars. Standard medical photogra­
phy is essential for surgical planning as well as for evaluat­
ing results. It is imperative to include anterior, anterior
oblique, lateral, posterior, and posterior oblique views when
planning circumferential body contouring procedures.
Standard anterior, oblique, and lateral facial views are used
for facial lipoplasty. The arms are photographed separately,
taking anterior/posterior views with the patient upright
and the elbows flexed 90°. Photographic consistency with
these procedures.21 Using third generation VAL, the author
frequently performs high volume lipoplasty with acceptable
results on healthy but significantly overweight patients
with moderate skin tone and poorly defined fatty deposits
(Fig. 50.16).
FIG 50.16 APPEARS ONLINE ONLY
Potential liposuction patients undergo an extensive
consultation including a thorough medical history and
physical examination. Even though UAL has expanded the
parameters for liposuction patient selection, one criterion
that remains unchanged is that the patient should be in
good health to undergo an elective, esthetic surgical pro­
cedure. In addition, take note of and discontinue com­
monly used, nonprescription medications that may affect
platelet function.
Risk factors that could potentially lead to deep vein
thrombosis (DVT) and pulmonary emboli (PE) should be
carefully examined in these patients. Teimurian and Rogers22
reported an incidence of DVT of approximately 33/100 000
and PE of approximately 12/100 000 in a survey of over
75 000 major liposuctions. In a survey of members of the
American Society for Aesthetic Plastic Surgery, Grazer and
de Jong23 reported a mortality rate of 19/100 000 for patients
FIG. 50.17  Preoperative markings are performed in the standing position. Contour irregularities are marked in red.
A
B

547.e1
Chapter | 50  Ultrasonic liposuction
FIG. 50.16  Third generation UAL devices have expanded the patient selection criteria for liposuction to include overweight patients with
moderate skin tone and poorly defined fatty deposits. (A) Preoperative appearance (B) Circumferential VAL with total aspirate volume of 11.5 liters.
A
B

548
PART | 7  Liposuction and fat grafting
attention to details such as lighting, backdrops, focal dis­
tance and positioning ensures accurate preoperative and
postoperative comparisons.
Preoperative markings are performed in the standing
position. Waterproof markers of different colors are used to
outline the specific areas planned for contouring, contour
irregularities (marked in red) and incision sites [Fig 50.17].
The specific areas to be contoured will vary from patient
to patient. However, there are five distinct anatomical areas
that should be avoided in patients undergoing SAL or
UAL. These areas, termed the “zones of adherence”
(Fig. 50.18), include: the (1) gluteal crease, (2) lower lateral
thigh area of the iliotibial tract, (3) posterior distal thigh
above the popliteal crease, (4) mid-medial thigh area and
(5) lateral gluteal depression area. Violation of these areas
with either UAL probes or suction cannulae often leads to
iatrogenic contour deformities. During the preoperative
marking process, pay close attention to the placement of
the access incisions. UAL requires a greater number of
slightly longer access incisions to accommodate the skin
protectors and avoid placing torque on the ultrasonic probe
over curved anatomical areas. Whenever possible, the
author prefers to mark the patient in the office the day
before surgery, photograph the markings and review them
with the patient. This procedure helps the patient have a
better understanding of the surgical plan and avoids misun­
derstandings regarding the extent of the contouring or
the placement of the incisions. Setting appropriate patient
expectations preoperatively avoids having to manage them
postoperatively.
SURGICAL TECHNIQUE
General Guidelines
With few exceptions, it is generally agreed that circumfer­
ential contouring leads to a more harmonious esthetic result
than “spot” liposuction. This is true for both for SAL and
UAL procedures. In most cases, patients will need to be
repositioned on the operating table in order to have access
to circumferential contouring. General endotracheal anes­
thesia is preferred for patients requiring the prone position
and for large volume aspirations. For circumferential pro­
cedures, the anesthesia induction and endotracheal intuba­
tion are performed on the stretcher adjacent to the operating
table, after which the patient is transferred directly to the
operating table into the prone position with the arms
extended forward and flexed at the elbows. This position
requires meticulous padding of all pressure points from
bony prominences, and proper protection of the breasts and
face (Fig. 50.19). A soft hip roll is placed beneath the
patient at the level of the iliac crests as well as an axillary
roll beneath each axilla. Flexing the operating table pro­
vides better linear access for the ultrasonic probes over the
curved anatomical areas of the back and flanks, thus mini­
mizing torque on the probes at the point of entry. The prone
position provides good access to the back, flanks, lateral
thighs and superior posterior thigh. This position also
makes it easier for the surgeon to assess symmetry during
liposuction by allowing visual inspection of both sides of
the posterior trunk and thighs simultaneously. Another
advantage of the prone position for circumferential liposuc­
tion is that it requires only one additional patient reposition­
ing to supine for completion of the anterior areas. In spite
of these advantages, many surgeons experienced in body
contouring, including the author, frequently perform UAL
contouring of the posterior areas in the lateral decubitus
position. Even though this type of liposuction positioning
requires one more patient repositioning (side to side plus
supine versus prone to supine), the author and others feel
this position offers better access with less trauma. It is
particularly helpful for evacuating large volumes from the
FIG. 50.18  The following areas are zones of adherence and should
be avoided; (1) gluteal crease (2) lower lateral thigh (3) posterior distal
thigh above popliteal crease (4) mid-medial thigh area (5) lateral
gluteal depression area.

549
Chapter | 50  Ultrasonic liposuction
Whenever lidocaine is used in the wetting solution, the total
dose should not exceed 35 mg/kg even though some authors
claim to routinely use doses exceeding 50 mg/kg while
maintaining a safety margin.27 Since most major circumfer­
ential liposuctions require general anesthesia and smaller
procedures without general anesthetics do not require
such high volumes of wetting solution, there really is no
good reason to push the limits of lidocaine toxicity in these
patients.
The author’s protocol is to infiltrate one area and imme­
diately proceed with the solid probe ultrasound to that
area, even though the full vasoconstrictive effect of the
epinephrine in the wetting solution may take up to 15
minutes. Unlike suction cannulae, gently passing third gen­
eration ultrasonic probes through the subcutaneous tissue is
not associated with bleeding. Prior to aspirating the ultra­
sound treated area, the next area in line for treatment under­
goes infusion of the wetting solution. Using this infusion
protocol, the author has on many occasions employed
cumulative epinephrine dosages of up to 14 mg without
complications.
UAL Posterior Trunk
The back and flanks are one of the most common areas for
which patients seek liposuction. The relative thickness of
the back dermis makes it forgiving and capable of camou­
flaging irregularities; however, the back fat is dense and
fibrous, making it difficult to aspirate by SAL. This is an
area which is also associated with greater amounts of blood
in the aspirate. The back rolls in particular have been
extremely difficult to correct by means of traditional SAL.
Currently the author utilizes VAL for all posterior trunk
contouring. This technology is highly efficient at emulsify­
ing back fat with minimal tissue trauma and the resulting
aspirate is practically bloodless. The endpoint in any lipo­
suction should be the presence of bloody aspirate, and in a
large reported series the author was able to extract three
times more fat from the back using VAL without bloody
aspirate than when using SAL.28 Both the prone and lateral
decubitus positions provide good access to these areas. The
incisions need to provide straight access to the area since
ultrasonic probes should not be subjected to torque. Use
skin protectors and a wet sponge around the incision. Infu­
sion of the wetting solution can be performed fairly rapidly
in this area, at approximately 400 ml/min, dispersing the
fluid evenly throughout the subcutaneous space. The author
uses a 3.7 mm two-ring probe for most of the back and
flank areas at 80% energy level in continuous mode and a
3.7 mm one-ring probe for the tight fibrous back rolls at
80% energy level in continuous mode. The author seldom,
if ever, has the need to use energy levels higher than 80%
to achieve proper emulsification, even in tight fibrous
flanks and back in the creation of esthetic waistlines.
The supine position is used for access to the abdomen,
anterior and medial thighs, knees, calves, ankles, arms,
breasts, and face.
FIG 50.19 APPEARS ONLINE ONLY
Mild hypothermia is a common occurrence in most of
these patients and is the result of a combination of factors
encountered during these operations. The large quantities
of infiltrating solution dispersed within the subcutaneous
space, the large body surface areas exposed and the ther­
moregulatory changes caused by prolonged general anes­
thesia are all factors contributing to the hypothermia. Using
forced warm air by means of a Bair Hugger®(Arizant Inc,
Eden Prairis, MN) over the head and neck area and all other
nonoperative areas is an effective way to combat hypother­
mia during these procedures. Running the intravenous
fluids through a fluid warmer is also helpful in maintaining
the core body temperature in these patients.
It was once commonplace to perform the operative
prepping for circumferential liposuction prior to the induc­
tion of anesthesia, using a Povidone Iodine (Betadine®)
solution spray in a circumferential fashion with the patient
in the standing position. Afterwards, the patient would lie
down on sterile sheets placed over the operating table
and the surgical draping would be completed. Currently,
many surgeons, including the author, prefer to prep and
drape an anesthetized patient in the proper position on
the operating table using Povidone Iodine (Betadine®)
gel. The access incisions are performed in the previously
marked areas using a #11 blade and of sufficient length to
accommodate the fluid infiltrating cannula. The rate of flow
is controlled on the infusion pump according to the ana­
tomical area. For example, in face and neck the fluids are
infiltrated slowly at a rate <200 ml/min, while on the pos­
terior trunk the infusion rate may be 400 ml/min. Even
though the “superwet” guidelines call for an approximate
1 : 1 ratio of fluid infiltrate to expected aspirate, the author
prefers to infiltrate until there is even distribution of the
fluid throughout the fat, creating a blanched and turgid
treatment area. This frequently exceeds the 1 : 1 ratio
originally described for SAL but the extra fluid in the
tissues proves advantageous in UAL both for promotion
of cavitation and for thermal protection. A number of
wetting solution formulas have been described in the litera­
ture.24–26 Formulas that advocate warming the wetting solu­
tion are not recommended for UAL procedures. For most
major UAL cases under general anesthesia, the author
employs a wetting solution consisting of 1 ml epinephrine
1 : 1000 added to 1 liter Ringer’s lactate at room tempera­
ture (1 : 1 000 000 dilution). In the occasional small case
where general anesthesia is not utilized, 30 ml of 1%
lidocaine is added to each liter of the wetting solution.

549.e1
Chapter | 50  Ultrasonic liposuction
FIG. 50.19  (A) The prone position for UAL allows the surgeon simultaneous visual inspection of both sides for assessment of symmetry.
(B) The position requires meticulous padding of pressure points at the bony prominences, as well as protection of the breasts and face.
A
B

550
PART | 7  Liposuction and fat grafting
FIG. 50.25  Circumferential VAL of the abdomen, flanks and back in a 34-year-old female. (A, B, C) Preoperative appearance. Total aspirate
volume was 6800 ml: (D, E) 3600 ml from the abdomen and flanks and (F) 3200 ml from the posterior trunk.
A
B
C
D
E
F
areas. The endpoint for the ultrasound is lack of tissue
resistance to the ultrasonic probe. The posterior trunk areas
require slightly longer ultrasound application,29 usually
between 12 and 14 minutes on average. Emulsified fat can
be rapidly extracted by means of a small diameter cannula.
The author performs most of the aspiration with a 3 mm
VentX cannula which is very precise and causes minimal
trauma. Examples of posterior trunk VAL are depicted in
Figs 50.20–50.22.
FIG 50.20, 50.21, 50.22 APPEARS ONLINE ONLY
UAL Abdomen
UAL of the abdomen is performed in the supine position.
The wetting solution is infused at 300 ml/min and a 3.7 mm
three-ring ultrasonic probe is used at an energy setting of
80% in VASER mode. The continuous mode is used for the
area above the costal margin. The average ultrasound time
for the abdomen is 8 to 9 minutes. Aspiration is accom­
plished with a 3 mm VentX cannula. Examples of abdomi­
nal VAL are depicted in Figs 50.23–50.25. Circumferential
contouring of the trunk is also recommended for males
(Fig. 50.26).
FIG 50.23, 50.24 APPEARS ONLINE ONLY
UAL Extremities and Buttocks
UAL of the knees, medial and anterior thighs is performed
in the supine position. The wetting solution is infused at
300 ml/min and a 3.7 mm, three-ring ultrasonic probe is
used at an energy setting of 70% in VASER mode for the
superior medial thigh. A short, 3 mm three-ring probe is
easier to maneuver around the knees in 80% VASER mode
and the same probe and settings are used for the superior
posterior thigh (banana roll). UAL of the anterior and lateral
thigh areas is also performed with the 3.7 mm three-ring
probe in 80% VASER or continuous mode, depending on
how fibrous the subcutaneous layer may be. Average ultra­
sound time is approximately 3 minutes for both knees, 5
minutes for both superior-medial thighs, 8 minutes for both
anterior thighs, 6–7 minutes for both lateral thighs and 4
minutes for both banana roll areas. Infusion of the brachial
area is performed slowly at 200 ml/min. A 3 mm three-ring
probe is inserted into the subcutaneous space through a
small access incision in the axillary fold so that the tip of
the probe moves away from the axilla. The energy setting
is 70% VASER mode applied for approximately 2 minutes
per arm. All the aspiration is performed with 3 mm VentX
cannulae. Examples of extremity and buttock VAL contour­
ing are depicted in Figs 50.27–50.29.
FIG 50.27, 50.28 APPEARS ONLINE ONLY
UAL Treatment of Gynecomastia
Treatment of gynecomastia is performed with the patient in
the supine position. UAL induced cavitation targets only fat
tissue for fragmentation so it is not unusual for some
patients to require open resection of glandular tissue after
aspiration of the emulsified fat. In the author’s experience

550.e1
Chapter | 50  Ultrasonic liposuction
FIG. 50.21  Circumferential VAL of the abdomen, flanks and back in a 20-year-old female. (A, B) Preoperative appearance. Total aspirate volume
was 6200 ml: (C) 3800 ml from the abdomen and flanks and (D) 2400 ml from the posterior trunk.
A
B
C
D
FIG. 50.20  Circumferential VAL of the abdomen, flanks and back in a 30-year-old female. (A, B) Preoperative appearance. Total aspirate volume
was 5400 ml: (C) 2800 ml from the abdomen and flanks and (D) 2600 ml from the posterior trunk.
A
B
C
D

550.e2
PART | 7  Liposuction and fat grafting
FIG. 50.23  Circumferential VAL of the abdomen, flanks, back and thighs in a 28-year-old female. (A, B, C) Preoperative appearance. Total
aspirate volume was 8800 ml: (D, E) 3600 ml from the abdomen and flanks and (F) 2800 ml from the posterior trunk.
A
B
C
D
E
F
FIG. 50.22  Circumferential VAL of the abdomen, flanks and back in a 23-year-old female. (A, B) Preoperative appearance. Total aspirate volume
was 11 500 ml: (C) 7300 ml from the abdomen and flanks and (D) 4200 ml from the posterior trunk.
A
B
C
D

550.e3
Chapter | 50  Ultrasonic liposuction
FIG. 50.24  Circumferential VAL of the abdomen and flanks in a 32-year-old female. (A, B, C) Preoperative appearance. Total aspirate volume
was 4600 ml: (D, E) 2400 ml from the abdomen and flanks and (F) 2200 ml from the lower back and posterior flanks.
A
B
C
D
E
F
FIG. 50.27  Circumferential VAL of the thighs, abdomen, flanks and back in a 28-year-old female. (A, B) Preoperative appearance. Total aspirate
volume was 8800 ml: (C, E) 2400 ml extracted from the thighs.
A
B
C
D

550.e4
PART | 7  Liposuction and fat grafting
FIG. 50.28  Moderate VAL aspiration volumes in older patients can yield acceptable esthetic results. Circumferential UAL of the thighs in a
58-year-old female. (A, B) Preoperative appearance. (C, D) 2200 ml extracted from the thighs.
A
B
C
D

551
Chapter | 50  Ultrasonic liposuction
FIG. 50.26  Circumferential VAL of the abdomen and flanks in a 36-year-old male. (A, B, C) Preoperative appearance. Total aspirate volume was
5800 ml: (D, E) 3800 ml from the abdomen and anterior flanks and (F) 2000 ml from the posterior flanks.
A
B
C
D
E
F
most cases of gynecomastia are successfully treated closed
with UAL; however, one should not hesitate to evacuate the
fibrous, glandular tissue if it is present in such quantities
that it would compromise the esthetic result. This tissue is
usually present beneath the areola and can be easily resected
through a small periareolar incision. The wetting solution
is infused rapidly, over 300 ml/min, in greater quantities
than for other areas. This is one anatomical area where
increased fluid pressure in the interstitial space is advanta­
geous. The 3.7 mm one-ring probe or the gynecomastia
“arrow” probe can be used efficiently in this area. The
arrow probe has an aggressive tip design well suited for
extremely fibrous tissue but it may be associated with more
bleeding. When using this probe the surgeon should allow
enough time after infusion for the epinephrine effect to take
place. VAL energy levels are set at 80–90% in the continu­
ous mode for an average of 3–4 minutes per breast, depend­
ing on size. Aspiration is performed using the short 3 mm
VentX cannula. An example of UAL treatment of gyneco­
mastia is depicted in Fig. 50.30.
UAL Face and Neck
UAL contouring of the face and neck is a common and
useful procedure in patients with significant facial and
neck fat or as an adjunct to facial rejuvenation proce­
dures.30 In order to avoid torque on the ultrasonic probe,
the author recommends three access incisions; one behind
each earlobe and one in the submental crease. Smaller
diameter, highly precise instrumentation is used for facial
VAL (Fig. 50.31). The wetting solution is slowly infused
at a rate of 200 ml/minute. The ultrasound is applied by
2.4 mm three-ring ultrasonic probes at 50–60% energy
levels in VASER mode for approximately 2–3 minutes.
Aspiration is performed with a 2.4 mm VentX cannula.
Examples of VAL neck contouring are depicted in Figs
50.32 and 50.33.
FIG 50.31, 50.32 APPEARS ONLINE ONLY
UAL Treatment of HIV-Associated
Cervicodorsal Lipodystrophy
Current therapy for human immunodeficiency virus (HIV)
includes medical suppression of viral replication by means
of highly active antiretroviral therapies (HAART). These
drugs have increased survival for HIV-infected patients
but their use is associated with a number of metabolic
complications. Of interest to plastic surgeons is an abnor­
mal fat redistribution associated with these drugs. Abnor­
mal fat deposits in the neck, particularly the cervicodorsal
region, are not only an esthetic concern but are highly
symptomatic.31 Hultman et al32 reported that UAL is well
suited for the treatment of this extremely fibrous cervico­
dorsal fatty deposit. An algorithm for the surgical manage­
ment of these conditions has been suggested by Davidson
et al.33
Wetting solution volumes are similar to those used in
gynecomastia and are infused at a rate of 300 ml/minute. A
3.7 mm one- or two-ring probe is used, depending on the
fibrous nature of the area. The energy setting is 80%

551.e1
Chapter | 50  Ultrasonic liposuction
FIG. 50.31  Facial VAL with the third generation devices is per­
formed with very precise, small diameter (2.4 mm) VASER probes
and (2.4 mm) VentX cannulae.

551.e2
PART | 7  Liposuction and fat grafting
FIG. 50.32  VAL contouring of the neck in a 44-year-old female. (A, B) Preoperative appearance. A 2.4 mm three-ring VASER probe was used at
60% energy level applied for 1 minute, 40 seconds in pulsed (VASER) mode. (C, D) A total aspirate volume of 70 ml was extracted.
A
B
C
D

552
PART | 7  Liposuction and fat grafting
FIG. 50.29  Three examples of VAL buttock reshaping. (A, B, C) Treatment areas are shaded. (D, E, F) Preoperative appearance. VAL aspirate
removed from bilateral shaded areas (G) 1800 ml (H) 2000 ml (I) 2000 ml.
A
B
C
G
H
I
D
E
F

553
Chapter | 50  Ultrasonic liposuction
FIG. 50.30  VAL treatment of gynecomastia in a 44-year-old male. (A, B) Preoperative appearance. A single ring VASER probe was used at 90%
energy level applied for 7 minutes total in continuous mode. (C, D) A total aspirate volume of 720 ml was extracted.
A
B
C
D
continuous mode and the time will vary according to the
volume of fat being treated. The endpoint, as always, is lack
of tissue resistance on the probe. Aspiration is performed
with a 3 mm VentX cannula. An example of VAL treatment
of cervicodorsal lipodystrophy is depicted in Fig. 50.34.
OPTIMIZING OUTCOMES
● Apply the least amount of ultrasound energy necessary
to obtain fat emulsification.
● The surgeon must be familiar with the clinical endpoint
of ultrasound application (loss of tissue resistance
against the ultrasonic probe).
● Plan incision placement to facilitate direct access to the
treatment area (avoid placing torque on the ultrasonic
probe).
● Small diameter cannulae provide greater precision, par­
ticularly in the aspiration of superficial fat. (UAL emul­
sified fat flows easily through 3 mm cannulae.)
● Liberal use of wetting solution evenly dispersed
throughout the fat increases the efficiency of ultrasonic
cavitation, minimizes blood loss and provides extra pro­
tection against the thermal effects of UAL.
● Circumferential contouring yields a more harmonious
esthetic result than “spot” fat extraction.
● Postoperative use of foam, compression garments,
lymphatic drainage massage and skin moisturizing regi­
mens can optimize UAL outcomes and decrease recov­
ery time.
POSTOPERATIVE CARE
Large volume UAL procedures require close monitoring
of fluid replacement and urine output. The aspirate is said
to contain less than one third of the wetting solution
infused. The other portion, approximately 70% of the
infused volume, does not eventually get absorbed into

554
PART | 7  Liposuction and fat grafting
FIG. 50.33  VAL contouring of the neck in a 52-year-old female. (A, B) Preoperative appearance. A 2.4 mm three-ring VASER probe was used at
60% energy level applied for 2 minutes in pulsed (VASER) mode. (C, D) A total aspirate of 85 ml was extracted.
A
B
C
D

555
Chapter | 50  Ultrasonic liposuction
FIG. 50.34  VAL contouring of HIV-associated cervicodorsal lipodystrophy in a 48-year-old female. (A, B, C) Preoperative appearance. A double
ring VASER probe was used at 80% energy level applied for 3 minutes, 40 seconds in continuous mode. (D, E, F) A total aspirate volume of 340 ml
was extracted.
A
B
C
D
E
F
the intravascular space as previously thought.34 The
higher the volume infused, the higher the unquantifiable
losses through the access incisions due to the increased
internal pressures created by the fluid. Even following the
aspiration phase, one can perform rolling massage of the
treated area, removing a significant volume of the free
fluid in the tissues through the access incisions. Postoper­
atively, most patients with large volume aspirations con­
tinue 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 taken into account when
planning fluid replacement. However, the amount
absorbed is not 70% of the initial infusion, the losses
through the incisions are difficult to quantify, and there is
significant variability among patients. These factors create
difficulties in the management of these patients using a
“one size fits all” formula. For these reasons, the author
prefers to leave an indwelling Foley catheter overnight in
all large volume UAL cases and manage the intravenous
fluids in accordance with maintaining a urine output of
approximately 1 ml/kg/hour. Patients are allowed oral
intake of fluids as soon as they are awake, early ambula­
tion is encouraged and they are discharged on the first
postoperative day.
The author applies foam and compression garments to
most UAL patients in the immediate postoperative period,
with the exception of circumferential, large volume extrac­
tions that display early high fluid drainage through the
access incisions. These patients can usually wear the com­
pression garments after 24 to 48 hours when most of the
fluid leakage has subsided. Lymphatic drainage and skin
moisturizing regimens are helpful as soon as the patient can
tolerate them. The postoperative photography is performed
at least 2 months after the surgery.
UAL COMPLICATIONS AND
THEIR MANAGEMENT
Complications in UAL can be divided into those associ­
ated with liposuction surgery and those directly associ­
ated with the application of ultrasound energy. The most
common complications of liposuction procedures are
under-extraction, over-extraction or irregular extraction.35
These are for the most part preventable complications.
The use of an intraoperative flow sheet documenting infu­
sion and aspiration volumes for each area is essential for
keeping track of the extraction volumes, although “it is
not what is removed that is so much important, but what
is left behind”36 and there is no substitute for attention
to detail on the part of the surgeon. Under-correction
is usually corrected by revisionary extraction, over-
correction may require fat grafting and the author has
found that irregularities or contour deformities respond
well to external ultrasound treatments (Fig. 50.35). Pares­
thesias, edema and ecchymosis are usually self limiting
and appear less prominently in UAL than in SAL (Fig.
50.36). The use of foam under the compression garments

556
PART | 7  Liposuction and fat grafting
is beneficial in diminishing the intensity and shortening
the time period for these sequelae. Complications related
to DVT, hypothermia and fluid replacement have been
previously discussed in this chapter. Complications
related directly to the use of ultrasound energy are cate­
gorized as those related to surgeon error and those related
to the design of the device.37 The vibrating ultrasonic
probe generates heat which could lead to thermal injury,
particularly around the incision site. The use of skin pro­
tectors is essential and the use of a wet towel adjacent to
the incision provides extra protection; however, the most
important factor in preventing skin burns is avoiding
torque on the probe. Unlike in SAL where the surgeon
may use the incision site as a fulcrum to torque a cannula
into a curved anatomical area, UAL probes require direct
linear access to the treatment area and may require addi­
tional incisions to achieve this.
Seromas (subcutaneous fluid accumulations) following
UAL are usually the result of too much ultrasonic energy
applied to the tissues either as a result of increased gen­
erator settings or prolonged application. In the author's
experience it is seldom necessary to use energy settings
above 80% applied for 1 to 1.5 min/100 ml of wetting
solution to a particular area in order to achieve proper
tissue fragmentation and emulsification. It is imperative
that the surgeon be familiar with the endpoints of UAL
treatment. Some authors advocate the use of drains par­
ticularly in the abdomen for large volume cases. Aspira­
tion and compression may be necessary for persistent
seromas.
Design flaws led to painful dysesthesias reported with
the use of the early first generation devices. These were the
results of demyelination of peripheral nerves from exces­
sive ultrasonic energy and are a rare and transient phenom­
enon with the third generation devices.
CONCLUSION
The use of ultrasonic devices has expanded the patient
selection criteria for liposuction. What was once considered
large-volume SAL38 is now considered a moderate UAL
extraction by most surgeons as a result of the negligible
blood loss, minimal surgeon fatigue, and a better under­
standing of the use of wetting solutions and fluid replace­
ment. One of the goals of UAL is to efficiently emulsify fat
while delivering the least amount of ultrasound energy to
the tissues. The third generation devices operate in a safer,
more efficient manner while delivering approximately 50%
of the energy to the tissues that their predecessors did.
Aspirate harvested by means of these new devices contains
viable fat cells and is highly suitable for fat grafting.
Although UAL is not viewed as a replacement for SAL, it
is considered the procedure of choice for large volume
FIG. 50.35  The MC1 external ultrasound device has been shown to
be effective in correcting post liposuction irregularities. The lymphatic
drainage component of the device is also helpful in minimizing post
surgical edema.

557
Chapter | 50  Ultrasonic liposuction
FIG. 50.36  VAL post surgical ecchymosis and edema is less than for SAL and usually subsides within 60 days even in large volume aspira­
tions. (A) Preoperative appearance of a 29-year-old female. (B) 48 hours post circumferential VAL to trunk with total aspirate volume of 6600 ml. (C)
30 days postoperative (D) 58 days postoperative.
A
B
C
D
aspirations, gynecomastia and other tight, fibrous anatomi­
cal areas where greater blood loss and suction trauma are
expected.
REFERENCES
1. The American Society for Aesthetic Plastic Surgery. Cosmetic
Surgery National Data Bank, Procedural Statistics; 2012.
2. Scuderi N, Devita R, D’Andrea F, et al. Nuove prospettive nella
liposuzione la lipoemulsificazone. Giorn Chir Plast Ricostr ed Estet­
ica 1987;2(1):33–9.
3. Zocchi ML. New prospective in liposculpturing: the ultrasonic
energy. Zurich, Switzerland: Proceedings of the 10th ISAPS Con­
gress; 1989.
4. Zocchi ML. Metodo di trattamento del tessuto adipose con energia
ultrasonic. Rome, Italy: Congresso dell Societa Italiana di Medicina
Estetica; April 1988.
5. Zocchi ML. Clinical aspects of ultrasonic liposculpture. Perspect
Plast Surg 1993;7:153–74.
6. Fredricks S. Analysis and introduction of a technology: ultrasound
assisted lipoplasty task force. Clin Plast Surg 1999;26(2):
187–204.
7. DiSpaltro FL. Ultrasound assisted lipoplasty. Clin Plast Surg 1999;
26(2):preface.
8. Chang C, Commons GW. A comparison of various ultrasound tech­
nologies. Clin Plast Surg 1999;26(2):261–8.
9. Zocchi ML. Ultrasonic assisted lipoplasty. Clin Plast Surg 1996;23
(4):575–98.
10. Cimino WW. History of ultrasound assisted lipoplasty. In: Shiffman
MA, Di Giuseppe A, editors. Body Contouring: Art, Science and
Clinical Practice. Berlin: Springer-Verlag; 2010. p. 399–403.
11. Jewell ML, Fodor PB, de Souza Pinto EB, et al. Clinical application
of VASER-assisted lipoplasty: a pilot study. Aesth Surg J 2002;22:
131–46.
12. Garcia O, Nathan N. Comparative analysis of blood loss in suction-
assisted lipoplasty and third generation internal ultrasound-assisted
lipoplasty. Aesth Surg J 2008;28:430–5.
13. De Souza Pinto EB, Abdala PC, Maciel CM, et al. Liposuction and
VASER. Clin Plast Surg 2006;33:107–15.
14. Cimino WW. Ultrasonic surgery: power quantification and efficiency
optimization. Aesth Surg J 2001;21(3):233–40.
15. Cimino WW, Bond LJ. Physics of ultrasonic surgery using tissue
fragmentation: part I. Ultrasound Med Biol 1996;22(1):89–100.
16. Cimino WW, Bond LJ. Physics of ultrasonic surgery using tissue
fragmentation: part II. Ultrasound Med Biol 1996;22(1):101–12.

558
PART | 7  Liposuction and fat grafting
17. Mendieta CG. Gluteal reshaping. Aesth Surg J 2007;27(6):
641–55.
18. Panetta NJ, Gupta DM, Kwan MD, et al. Tissue harvest by means
of suction assisted or 3rd- generation ultrasound assisted lipoaspira­
tion has no effect on osteogenic potential of human adipose-derived
stromal cells. Plast Reconstr Surg 2009;124(1):65–73.
19. Rohrich RJ, Raniere J, Beran SJ, et al. Patient evaluation and indica­
tions for ultrasound assisted lipoplasty. Clin Plast Surg 1999;26(2):
269–78.
20. Hughes CE. Patient selection, planning and marking in ultrasound
assisted lipoplasty. Clin Plast Surg 1999;26(2):279–82.
21. Commons GW, Halperin B, Chang CC. Large-volume liposuction:
a review of 631 consecutive cases over a 12 year period. Plast
Reconstr Surg 2001;108(6):1753–63.
22. Teimorian B, Rogers WB. A national survey of complications associ­
ated with suction lipectomy: a comparative study. Plast Reconstr
Surg 1989;84:628.
23. Grazer FM, de Jong RH. Fatal outcomes from liposuction: census
survey of cosmetic surgeons. Plast Reconstr Surg 2000;105(1):
436–46.
24. Klein JA. The tumescent technique for liposuction surgery. Am J
Cosmetic Surg 1987;4:263–7.
25. Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety
in liposuction (Editorial). Aesth Plast Surg 1995;19:379.
26. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltra­
tion in suction-assisted lipoplasty: a review. Plast Reconstr Surg
1997;99:514–9.
27. De Jong RH. Titanic tumescent anesthesia. Dermatol Surg 1998;
24:689–92.
28. Garcia O. Comparison of blood loss in suction assisted lipoplasty
and third generation ultrasound assisted lipoplasty. In: Shiffman MA,
Di Giuseppe A, editors. Body Contouring: Art, Science and Clinical
Practice. Berlin: Springer-Verlag; 2010. p. 565–73.
29. Garcia O. Aesthetic body contouring of the posterior trunk and but­
tocks using third generation pulsed solid probe ultrasound assisted
lipoplasty. In: Shiffman MA, Di Giuseppe A, editors. Body
Contouring: Art, Science and Clinical Practice. Berlin: Springer-
Verlag; 2010. p. 493–504.
30. Di Giuseppe A. The harmonic lift: ultrasonic assisted skin remodel­
ing. Int J Cosm Surg Aesthet Dermatol 2000;2(2):125–31.
31. Gold DR, Annino DJ. HIV-associated cervicodorsal lipodystrophy:
etiology and management. Laryngoscope 2005;115(5):791–5.
32. Hultman CS, McPhail LE, Donaldson JH, et al. Surgical manage­
ment of HIV-associated lipodystrophy: role of ultrasonic assisted
liposuction and suction assisted lipectomy in the treatment of lipo­
hypertrophy. Ann Plast Surg 2007;58(3):255–63.
33. Davidson SP,Timpone J, Hannan CM. Surgical algorithm for man­
agement of HIV lipodystrophy. Plast Reconstr Surg 2007;120(7):
1843–58.
34. Trott SA, Stool LA, Klein KW. Anesthetic considerations. In:
Rohrich RJ, Beran SJ, Kenkel JM, editors. Ultrasound-assisted Lipo­
suction. St. Louis: Quality Medical Publishing; 1998. p. 69–84.
35. Toledo LS, Mauad R. Complications of body sculpture: prevention
and treatment. Clin Plast Surg 2006;33(1):1–11.
36. Illouz Y-G. Principles of the technique. In: Illouz Y-G editor. Body
Sculpting by Lipoplasty. Edinburgh: Churchill-Livingstone; 1989.
p. 67.
37. Cimino WW. Ultrasound-assisted lipoplasty: basic physics, tissue
interactions and related results/complications. In: Shiffman MA, Di
Giuseppe A, editors. Body Contouring: Art, Science and Clinical
Practice. Berlin: Springer-Verlag; 2010. p. 389–98.
38. Fodor PB, Watson JP. Wetting solutions in ultrasound-assisted lipo­
plasty. Clin Plast Surg 1999;26(2):289–93.
Fig. 50.1, Fig. 50.2, Fig. 50.3, Fig. 50.6, Fig. 50.7, Fig. 50.9,
Fig. 50.10, Fig. 50.13, Fig. 50.14, Fig. 50.16, Fig. 50.19, Fig. 50.20,
Fig. 50.21, Fig. 50.22, Fig. 50.23, Fig. 50.24, Fig. 50.27, Fig. 50.28,
Fig. 50.31, Fig. 50.32 can be found online.
Bonus images for this chapter can be found online at

559
© 2013 Elsevier Inc
Chapter 51 
Key Points
●
High-intensity focused ultrasonic energy (HIFU) is
capable of thermal ablation of subcutaneous adipose
tissue (SAT) and will modulate collagen found within
the midlamellar matrix.
●
HIFU does not target vascular structures, unlike laser
energy delivered by fiber.
●
Following a HIFU treatment, the body removes the
cell debris and neocollagenesis occurs over time. The
ultimate result of contour improvement is at
approximately 12 weeks post-treatment.
●
Research studies demonstrate that there are no
abnormalities seen in blood chemistry and liver
function as the ablated SAT is resorbed.
●
The ideal candidate for HIFU body contouring has at
least 2.5 cm of tissue on caliper pinch and a BMI <30.
HIFU body contouring is not a weight loss treatment,
but a way to improve contour where there are areas of
fat deposits.
●
Ecchymosis in the treatment area is commonly seen,
but resolves rapidly afterwards.
●
A single treatment with a HIFU device in a research
study resulted in at least 2 cm of loss in waist
circumference over baseline measurements. There
were subgroups of patients that lost an average of
5.68 cm.
●
HIFU represents an option for noninvasive body
contouring that has an excellent safety profile.
High intensity focused ultrasound and
non-invasive body contouring
Mark L. Jewell and James L. Jewell
INTRODUCTION
Liposuction (lipoplasty) first appeared as a procedure
approximately 25 years ago as a technique to produce
contour improvements with a minimally invasive approach.
When it was introduced, it represented a quantum leap from
the Pitanguy-style body contouring through excision of skin
and fat deposits. Today, it remains a mainstay of esthetic
surgery and one of the most requested esthetic procedures.
Although a variety of attempts at noninvasive body contour­
ing with energy-based technologies have been proposed,
most had technological shortcomings, poorly-characterized
outcomes, and/or a poor risk–benefit profile. Even in situa­
tions where multimodal approaches of mechanical force,
laser, and radiofrequency energy have been used simultane­
ously, patients have not achieved uniformly satisfactory
results.
The theory of a noninvasive approach for body contour­
ing optimally involves the application of some sort of
energy to ablate adipocytes and tighten collagen that is
found within the midlamellar matrix of tissue (MLM). The
question that follows is how does one accomplish this task
and at the same time avoid fundamental problems with
tissue thermodynamics from bulk heating of tissue or full-
thickness epidermal injury. Energy-based systems that
utilize bulk heating of tissue appear only minimally better
than lipoplasty, but with substantive risk of tissue necrosis,
chronic inflammation, and occlusion of vascular structures.
Transcutaneous radiofrequency technologies become prob­
lematic due to treatment discomfort and risks of thermal
injury to skin.
Pharmacologic approaches (injection lipolysis or
“mesotherapy”) have been considered, yet remain problem­
atic because of the small areas that are treated and the
presence of chronic inflammation in tissues.1
Cold-based devices may improve contour, yet cannot be
expected to tighten collagen in the MLM. These heat sub­
traction treatment devices appear to produce contour
improvements through reduction of superficial fat and skin
retraction only. External low-level or “cold” laser tech­
niques have been reported as applicable for body contour­
ing, yet with poorly-controlled studies and short, meaningless
follow up periods.
This chapter will cover what appears to be a promising
technology of high-intensity focused thermal ultrasound
that is designed to improve body contour.
ULTRASONIC ENERGY
High intensity, focused ultrasonic energy (HIFU) has been
considered as a way to ablate tissue deep inside to body as
Part 8  Body contouring with HIFU or injectables

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PART | 8  Body contouring with HIFU or injectables
changes. Its use for body contouring would be considered
off-label because these devices are approved for tissue
heating. The safety and efficacy of external, nonfocused
ultrasound as a device for noninvasive body contouring has
not been determined. There have been other reports of the
use of external, nonfocused ultrasound as an adjunct for the
dispersion of wetting solutions used in surgical lipoplasty.4,5
Burns have been reported with nonfocused ultrasound.6
TISSUE THERMODYNAMICS
When considering energy-based applications for body
contouring, it is important to remember that all energy
ultimately becomes heat. The common approaches for
energy-based body contouring are divided into technolo­
gies that produce bulk heating/cooling of tissues or deliver
energy in a more targeted fashion, with minimal collateral
damage risk to skin, vascular/lymphatic structures, or
nerves.
A review of the biologic response of tissue to heating is
important to understand how energy-emitting devices affect
tissue and what would be considered reasonable safety
parameters. It takes approximately 4.184 J of energy to
raise 1 g of water 1°C in a linear fashion. Tissue response
to heating at around 43°C becomes nonlinear when there is
a break in the response curve. From this point upward,
small increases in tissue heating result in profound tissue
effects. Tissue damage has been noted at 44°C, blood
flow stops at 45°C, and tissue necrosis will occur at 47°C.
It takes tissue heating to 65–70°C to modulate collagen,
which is way beyond thermal levels for tissue necrosis.
Other factors that are involved in tissue injury relate to
the rate of tissue heating and whether thermal protective
a treatment for medical conditions (liver metastases, uterine
fibroids, and atrial fibrillation.2 Ultrasound propagates
through tissue at approximately 1540 m/s. Sonic energy,
like light, can be focused. Pressure fluctuations lead to
shearing motions and molecular-level interactions that
produce heat. Because it is focused to a predetermined point
within tissue, the energy can pass across the skin at rela­
tively low fluences of 1–3 J/cm2, yet reach greater than
1000 J/cm2 within the focal zone. In this fashion, a “track­
less” lesion is produced, without collateral damage to
surrounding tissue or skin. Figure 51.1 demonstrates a
Schlieren image of ultrasound waves that converge and
diverge beyond a focal zone. Ultrasound can be focused
at specific depths within the tissues as demonstrated in
Fig. 51.2.
Temperature measurements taken within porcine tissue
at the focal zone of a commercially available HIFU system
(the LipoSonix® system, Medicis Technologies Corpora­
tion, Bothell, WA, USA, technical data) approach 70°C,
while unaffected nearby tissues are normal (37°C).3
Nonfocused ultrasound is used for bulk heating of tissue
by physical therapists in low fluences of 2–5 W/cm2. While
this may have a therapeutic benefit for the treatment of
musculoskeletal conditions, some devices are capable
of bulk tissue heating in the 45–47°C range. This level of
tissue heat is problematic in terms of skin burns and tissue
necrosis. Currently, a dual-transducer ultrasound device is
being studied to determine if it can produce body contour
FIG. 51.1  Schlieren photography demonstrates ultrasound converg­
ing and diverging around a focal zone.
FIG. 51.2  HIFU allows for focused delivery of power at any depth
versus other technologies (RF or laser).
HIFU beam
100
80
90
60
40
20
70
50
30
10
0
4
6
18
20
2
10
12
14
16
8
Depth (mm)
Normalized power (%)

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Chapter | 51  High intensity focused ultrasound and non-invasive body contouring
FIG. 51.3  A hemorrhagic band is noted in the focus zone following
HIFU treatment.
FIG. 51.4  Macrophages remove cell debris and extracellular lipids.
measures are used (pulsed/pattern delivery of energy, lipo­
plasty wetting solution, or epidermal cooling).
Bulk heating of tissue via laser fiber, unfocused ultra­
sound, or radiofrequency can raise tissue temperatures far
beyond the range to produce thermal necrosis, yet not high
enough to modulate collagen (65–70°C). External tempera­
ture measurements are notoriously unreliable in measuring
heat levels in deeper layer tissues. Not all surgeons will pay
attention to temperature measurements when using devices
that perform bulk heating of tissue. Outcome studies pub­
lished show only minimal incremental benefit with bulk
heating technologies over existing approaches for surgical
lipoplasty.
Surgical lipoplasty with ultrasound utilizes a thermal
injury protective approach of wetting solutions that prevent
excess tissue heating.7 Solid probe devices will fragment
tissue at lower energy levels and pulsed energy reduces the
possibility of thermal damage.
HIFU will produce a direct thermal effect that results in
ablation of adipocytes and thermal modulation of collagen
fibers that are contained within the MLM. Animal studies
with thermocouples implanted in the HIFU target zone
demonstrate that temperature levels high enough to accom­
plish the intended effect (65–70°C) are reached and that
nearby tissue outside of the focal zone is not heated. HIFU
with the LipoSonix device is delivered in a grid-like pattern
where pulses of energy are applied to tissue and nearby
unheated tissue is used to dissipate heat. This is similar to
a pattern generator used by lasers for fractional skin treat­
ments. In both situations, there is enough untreated tissue
nearby that serves as a heat sink to prevent bulk heating
and bulk tissue damage.
TISSUE EFFECT AND BIOLOGY OF
THERMAL HIFU
HIFU produces an immediate coagulative necrosis of
tissue within its focal zone. A thermal effect is also pro­
duced in the collagen component of the MLM. Within the
tissue treated with HIFU, a hemorrhagic appearance of
the tissue is initially noted, as documented in Fig. 51.3.
Extracellular lipid and cell debris is removed by macro­
phages and transported to the liver via lymphatic chan­
nels. Figure 51.4 demonstrates foamy macrophages that
are removing cell debris and extracellular lipid. Collagen
remodeling occurs over time. The majority of remodeling
is completed by week 12, according to animal studies.
Within the preclinical and pivotal studies for the Lipo­
Sonix device, ecchymosis was frequently seen, yet
resolved by 12–16 days post-treatment. Tissue lumpiness
or contour irregularities were not encountered. The HIFU
lesions within treated tissue heal over time, as shown in
Fig. 51.5.
The biologic effect of thermal HIFU appears to be dif­
ferent than other forms of body contouring that use bulk
heating of tissue. While adipocyte necrosis results in the
release of extracellular lipids, fat necrosis and chronic
inflammation following HIFU treatment do not occur.
There is minimal collateral damage to tissue, with no
known effect on arterioles or lymphatic channels. A patent
arteriole that crosses the HIFU treatment zone is seen in
Fig. 51.6. Laser frequencies (900–1400 nm) used for lipo­
plasty (via fiberoptic delivery) are attracted to hemoglobin
and water chromophores. This will inflict collateral damage
on vascular and lymphatic structures. HIFU, like all other
forms of sonic energy, can produce self-limited dysesthe­
sias in cutaneous sensory nerves that are located within the
treatment zone.
THERMAL HIFU AS A NONINVASIVE BODY
CONTOURING DEVICE
Initial studies have established that thermal HIFU has a
predictable biologic effect for adipocyte ablation and
thermal modulation of collagen contained within the MLM.