274 39 External Ultrasound and Superficial Subdermal Liposuction procedure and to keep it there until the end to use it to correct any depression that might become evident. It is advisable to let the collected fat separate from the fluids present in the syringe before injecting it. The fat temporarily stored in the syringes must be aspi- rated from an area where EU has not been applied, otherwise the fat to be grafted would be less useful, having been crushed by the ultrasound wave. 39.10 Dressing A small Band-Aid is applied to every stab incision. Reston foam is applied to treat areas of the trunk for 2 days. Elastic stockings for the lower limbs and elas - tic garments for the trunk are applied at the end of the surgery. 39.11 Postoperative Care Antibiotics are given routinely at the beginning of the surgery and are continued 6 days after surgery. Early ambulation is encouraged to prevent venous throm- bosis. Elastic garments are worn for 6weeks as al - ready described in the section “Patient Information”. Endermologie treatment and/or lymphatic vein mas- sages are routinely indicated after 20 days. A well-bal - anced diet is prescribed including 2 l of fluid intake. 39.12 Complications Complications of SSL are very rare. Parasthesias is the more frequent (0.5%) and is the consequence of nerve injury when performing the suction. It sometimes may be permanent and is more frequent in the limbs. Waves and irregularities require further touch-ups after many months, at least six, when it is possible to evaluate the result and correctly indicate the treatment. Infections are also very rare, and include two cas- es of slight inflammation with erythema of the skin that healed in a few days after antibiotic therapy. Two patients that had been grafted with between 200 and 300 ml of fat developed an inflammation after the first week and were also successfully treated with an- tibiotics. We had no cases of thrombosis. Two seromas formed in abdominal liposuction after an attempt to use larger-gauge (1-cm) cannulae to speed the suction time. This confirms that if the SSL technique is cor- rectly performed there is no seroma formation and the procedure is highly reliable. No complications were ascribed to the use of EU. References 1. Fischer A, Fischer G: First surgical treatment for moulding body’s cellulite with three 5 mm incision. Bull Int Acad Cosmet Surg 1976;3:35–37 2. Kesselring UK: Regional fat aspiration for body contour- ing. Plast Reconstr Surg 1983;72(5):610–619 3. Illouz YG: Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg 1983;72(5):591– 597 4. Fournier PF: Liposculpture. The Syringe Technique. Ar- nette Blackwell, Paris, France 1991 5. Gasperoni C, Salgarello M, Emiliozzi P, Gargani G: Sub- dermal liposuction. Abstract of the 10th Congress of the International Society of Aesthetic Plastic Surgery, Zurich 11–14 September 1989:95 6. Gasperoni C, Salgarello M, Emiliozzi P, Gargani G: Sub- dermal liposuction. Aesth Plast Surg 1990;14:137–142 7. Gasparotti M: Superficial liposuction for flaccid skin pa- tients. Ann Int Symp Recent Adv Plast Surg, Sao Paulo, Brazil, March 28–30, 1990:441 8. Toledo LS: Superficial syringe liposculpture. Ann Int Symp Recent Adv Plast Surg, Sao Paulo, Brazil, March 28–30, 1990:446 9. Souza Pinto EB: Lipoinjerto y liposuction superficial. Me- moria XVI Congreso Nacional de Chirurgia, Santa Cruz de la Sierra, Bolivia. Abstract Book 1991:325–330 10. Goddio AS: Skin retraction following suction lipectomy by treatment site: a study of 500 procedures in 458 selected subjects. Plast Reconstr Surg 1991;87(1):66–75 11. Becker H: Subdermal liposuction to enhance skin con- traction: a preliminary report. Ann Plast Surg 1992;28(5): 479–484 12. Burkardt BR: Subdermal liposuction to enhance skin contraction: a preliminary report. Ann Plast Surg 1992;29(4):381 13. Avelar JM, Illouz YG: Lipoaspiraçao. Editora Hipocrates, Sao Paulo, Brazil, 1986. 14. Lookwood TE: Superficial Fascial System (SFS) of the trunk and lower extremity. A new concept. Plast Reconstr Surg 1991;87:1009–1018 15. Gasperoni C, Salgarello M: Safe and effective liposuction. Presented at the Annual Symposium of the Southeastern Society of Plastic and Reconstructive Surgeons held in Boca Raton, Florida, 5–9 June 1999 16. Rudkin GH, Miller TA: Lipedema: a clinical entity dis- tinct from lymphedema. Plast Reconstr Surg 1994;94(6): 841–847 17. Souza Pinto EB: Superficial liposuction and fat graft cel- lulitis. Recent Adv Plast Surg International, VI Annual Meeting, Beverly Hills, CA, July 20–21, 1991 18. Gasperoni C, Salgarello M, Cimino A, Gasperoni P: A new tool to eliminate hyperpigmentation in liposuction scars. Ann Plast Surg 2000;45(2):214–215 19. Klein JA: The tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Der- matol Surg Oncol 1990;16(3):248–263 20. Klein JA: The tumescent technique for liposuction sur- gery. Am J Cosm Surg 1987;4:263–267 21. Fodor PB: Defining wetting solutions in lipoplasty. Plast Reconstr Surg 1999;103:1519 275 22. Gasperoni C., Salgarello M., Gasperoni P. External ultra- sound used in conjunction with superficial subdermal li- posuction: a safe and effective technique. Aesthetic Plastic Surgery 2000;24:253–258 23. Gasperoni C., Salgarello M: The use of external ultra- sound combined with superficial subdermal liposuction. Ann Plast Surg 2000;45(4):369–373 24. Gasperoni C, Salgarello M: Rationale of subdermal super- ficial liposuction related to the anatomy of subcutaneous fat and the Superficial Fascial System. Aesth Plast Surg 1995;19(1):13–20 25. Gasparotti M: Superficial liposuction: a new application for aged and flaccid skin. Aesth Plast Surg 1992;16(2): 141–153 26. Gasperoni C, Salgarello M: MALL liposuction: the natural evolution of the subdermal superficial liposuction. Aesth Plast Surg 1994;18(3):253–257 27. Cook WR: Utilizing external ultrasonic energy to im- prove the results of tumescent liposculpture. Dermatol Surg 1997;23(121):1207–1211 28. Havoonjian HH, Luftman DB, Menaker GM, Moy RL: External ultrasonic tumescent liposuction. A preliminary study. Dermatol Surg 1997;23(12):1201–1206 29. Kinney BM, : Body contouring with external ultrasound. Plast Reconstr Surg 1999;103(2):728–729 30. Silberg BN: The technique of external ultrasound-assisted lipoplasty. Plast Reconstr Surg 1998;101(2):552 References External Ultrasound Before and After Tumescent Liposculpture William R. Cook Jr. C  40 40.1 Introduction Ultrasonic medical devices have been used as a di- agnostic and therapeutic tool for a number of years. Ultrasound has been used in neurosurgery, otolaryn- gology, ophthalmology, and urology, to name a few specialties, and has proven to be extremely useful and safe [1, 2]. Its use in physical therapy applications is well established [3]. Ultrasound has been used by cos- metic surgeons postoperatively to reduce swelling af- ter liposculpture, and more recently it has been used intraoperatively or preoperatively as well. After the development of tumescent liposculpture by Klein [4], the application of ultrasound to liposuc- tion surgery became a possibility, because ultrasonic energy requires a fluid medium to be transmitted and the tumescent fluid provides such a medium. Zocchi [5–7] of Italy first conceived the concept of applying ultrasonic energy to adipose tissue in the late 1980s. Ultrasound may be applied either internally or externally. Internal ultrasound, such as that used by Zocchi, utilizes a special probe or cannula, which generates the sound waves while inserted in the pa- tient’s body through the liposuction incisions. Thus, internal ultrasound is applied during the actual lipo- suction procedure. External ultrasound uses a flat, round transducer that is held against the skin in the areas to be treated. External ultrasound may be used on tumesced areas immediately before liposuction to facilitate the procedure, or on follow-up visits during the postoperative period to speed healing. The application of ultrasonic energy to the adipose tissue effectively liquefies the fat, releasing a combi- nation of triglycerides, normal interstitial fluid, and the infused tumescent solution. These components form an emulsion, which can be removed using vacu- um suction. Because of the predilection of the ultra- sonic waves for low-density tissue such as fat, there is felt to be a selective targeting of the fat cells without affecting the intervening connective tissue and neu- rovascular structures. The depth of penetration is in- versely proportional to the frequency used. It is felt that ultrasonic energy affects the adipose tissue via several mechanisms: thermally, micromechanically, and through the phenomenon of cavitation. Internal ultrasonic liposuction primarily utilizes the prin- ciples of cavitation. The exact mechanism by which external ultrasound affects fatty tissues is not cur- rently clear; however, it is felt to be a micromechani- cal effect [8]. The author has utilized internal ultrasonic liposuction in the past; however, there have been many reports of complications with this technique [9–13]. Reported complications have included per- foration of the abdomen, burning of incisional sites and overlying tissue, seromas, poor cosmetic results, and a variety of other complications. It is also cum- bersome to use the ultrasonic cannula and special- ized microcannulas are preferred, which produce consistently excellent results and do not have the side effects associated with internal ultrasound. For these reasons many surgeons have largely abandoned the internal technique. However, some practitioners have had success with limited use of internal ultra- sound. For example, Narins [14] reports good results using internal ultrasound for up to 2 min prior to traditional liposuction in fibrous areas such as the abdomen. Because of the problems associated with internal ultrasound the author has worked to develop the concept of external ultrasound [15]. External ultra- sonic energy may be used preoperatively to produce a more favorable result without the side effects and complications associated with internal ultrasound. External ultrasound may also be applied postopera- tively to reduce swelling and shorten the recovery course. Any surgeon utilizing ultrasonic energy for any purpose should be knowledgeable about its usage and side effects as well as possible complications. Also, any ancillary personnel should be adequately trained and experienced in the use of ultrasonic devices. 277 40.2 Preoperative External Ultrasound 40.2.1 Infusion Before being treated with external ultrasound prior to liposculpture, the patient must be thoroughly infused with tumescent solution to provide a medium for the conduction of the ultrasonic waves. The author uses two solutions for tumescent infiltration [16]. 1. A 0.1% lidocaine solution containing 1,000 mg/l lidocaine (0.1% concentration), 1 mg/l epineph- rine (1:1,000,000 concentration), 10 mEq/l sodium bicarbonate, and 10 mg/l triamcinolone acetonide (Kenalog). This solution is made up by taking 1,000 ml of sterile normal saline solution (0.9% NaCl) in an infusion bag and adding 10 ml of 8.4% sodium bicarbonate (1 mEq/ml) and 50 ml of 2% lidocaine (20 mg/ml). Immediately before infusion add 1 ml epinephrine (1 mg/ml or 1:1,000) and 1 ml triam- cinolone acetonide (Kenalog, 10 mg/ml). 2. A 0.05% lidocaine solution containing 500 mg/l lidocaine (0.05% concentration), 1 mg/l epineph- rine (1:1,000,000 concentration), 10 mEq/l sodium bicarbonate, and 10 mg/l triamcinolone aceton - ide (Kenalog). This solution is made up by tak- ing 1,00 ml of sterile normal saline solution (0.9% NaCl) in an infusion bag and adding 10 ml of 8.4% sodium bicarbonate (1 mEq/ml) and 25 ml of 2% lidocaine (20 mg/ml). Immediately before infusion add 1 ml epinephrine (1 mg/ml or 1:1,000) and 1 ml triamcinolone acetonide (Kenalog, 10 mg/ ml). The sodium bicarbonate and lidocaine can be added to the infusion bag up to 24 h in advance of surgery. However, the epinephrine and triamcinolone are add- ed just prior to infusion. This is important to ensure the effectiveness of the epinephrine as a vasoconstric- tor. Each bag must be carefully labeled with its exact contents with the date and the initials of the individ- ual who made the solution. Also, the infusion bag is heated to approximately 39–40°C in either a warm- water bath or a microwave oven prior to infusion. It is important to plan the amount of lidocaine that will be infused in a particular case. The estimated maximum allowable amount of lidocaine should be between 55 and 60 mg per kilogram of body weight. The physician should be well versed in the use of lido- caine, the lidocaine levels that are achieved, and the toxicity of lidocaine [17]. 40.2.2 Technique The liposculpture patients receive external ultra- sound preoperatively to all body and neck areas, with the exception of very thin necks. The Rich-Mar ex- ternal ultrasound unit (Rich-Mar, Inola, OK, USA) is used (Fig. 40.1). The energy applied is 1.0 W/cm 2 to body areas and 0.5 W/cm 2 to the lower face and neck, using a continuous wave at 1 MHz. The unit pictured has two transducers, one 10 cm in diameter for body areas and the other 5 cm in diameter for neck areas. The transducer should never be static. It should always be moved slowly and continuously in a circu- lar fashion over the areas to be treated. Ultrasound is applied for 10–15 min per body area (Fig. 40.2). To achieve the best conductivity of the ultrasonic energy between the transducer and the patient, a sterile ul- trasonic gel is used (PolySonic Ultrasound Lotion, Parker Laboratories, Fairfield, NJ, USA). In particu- larly fatty areas, moderate pressure can be applied to the transducer. Care should be taken never to apply Fig. 40.1. Rich-Mar ultrasound unit Fig. 40.2. Applying external ultrasound before tumescent lipo- sculpture 40.2 Preoperative External Ultrasound 278 40 External Ultrasound Before and After Tumescent Liposculpture the ultrasonic energy to bony areas or to areas that have not been tumesced. The probe should never re- main still on the body. In one study of 30 patients [15], preoperative ex- ternal ultrasound was administered to one side of the body and not the other. Only the nursing staff was aware of which side had been treated with the exter- nal ultrasound. Both the surgeon and the nursing staff recorded their observations as to swelling, bruis- ing, discomfort, and recovery time comparing the treated and untreated sides. The surgeon also noted the comparative ease of cannula movement, time of surgery, and consistency of the fatty aspirate. The cannulas proved to be easier to move and the time needed for the surgery was slightly less on the treated side. Patients had equally good cosmetic results on both sides. There was less bruising and swelling on the ultrasound-treated side, and the majority of pa- tients reported less discomfort on the treated side. A temperature probe was utilized during this study be- cause of an initial concern that the temperature might rise owing to the ultrasonic treatment. However, the temperature was actually slightly lower on the treated side. It was felt that this was probably due to decreased circulation in the area caused by the vasoconstrictor in the tumescent solution. No complications were noted during this study, and no complications were observed during continuous use of ultrasound in the years since the study [18–22]. The use of preoperative external ultrasound has been an important advance in liposculpture surgery. It facilitates the procedure for the surgeon, causes no demonstrable side effects, and gives the patients a rapider recovery with less postoperative swelling. 40.3 Postoperative External Ultrasound 40.3.1 Indications The author has used external ultrasound treatment postoperatively for selected liposculpture patients since 1990. The use of postoperative ultrasound de- creases swelling and discomfort, promotes rapid heal- ing, and is high in patient satisfaction. The author has experienced no complications from the postoperative use of ultrasound. Only patients who are symptomatic and show firm or persistent swelling are treated with postoperative ultrasound. Treatment is begun 1 week postopera - tively on average and is continued on a weekly basis as necessary. In areas that are significantly indurated, the sites may be injected with 1–5 ml triamcinolone (Kenalog), 1–5 mg/ml, prior to treatment with ultra- sound. If induration does not respond to this treat- ment, the concentration of the triamcinolone may be increased. 40.3.2 Technique For postoperative application of ultrasound the Rich- Mar ultrasonic unit is used. For body areas, 1.0 W/cm 2 is used and 0.5 W/cm 2 is used for the face and neck, using a continuous-wave setting at 1 MHz. The ultrasonic probe is moved in a gentle slow cir- cular rotation. No excessive pressure is required. To conduct the ultrasonic waves, a clear ultrasonic gel or lotion is utilized. The gel provides a more fluid sur- face to facilitate movement of the probe; however, pa- tients prefer the less sticky feeling of the lotion. The application of ultrasound to a given area should be started at one point and continuously moved through slow rotations to other points until the entire body area has been treated, then the appli- cation should be started again at the original point and the process repeated for 5–10 min per treatment session. Treatment is generally given on a weekly ba- sis until swelling and/or discomfort are resolved. It is important to avoid bony areas and neck cartilage while applying ultrasound. This technique has been shown to reduce postop- erative discomfort and swelling and to improve the recovery process in patients with firm or persistent postoperative swelling (Fig. 40.3). There may be other benefits as well. Narins [14] has reported that post- operative external ultrasound can help to eliminate postoperative vertical folds in the neck. There have been reports that postoperative exter- nal ultrasound may not be useful for all liposuction patients [23]. However, the consensus is that this is a very useful modality for properly selected patients, namely, those with firm or persistent induration or swelling [24]. In such patients, postoperative external ultrasound can speed recovery and improve patient comfort. References 1. Dyson M. Therapeutic applications of ultrasound. IN Nuborg WI, Siskin MC, eds, Biological Effects of Ultra- sound: Clinics in Diagnostic Ultrasound. New York: Churchill-Livingstone 1985:121–131. 2. Kitchen SS, Partridge CJ. A review of therapeutic ultra- sound, part 1: Background and physiological effects. Phys- iotherapy 1990;76:593–600. 3. Kuitert JF. Ultrasonic energy as an adjunct in the manage- ment of radiculitis and similar referred pain. Am J Phys Med 1954;33:61–65. 4. Klein JA. The tumescent technique for liposuction sur- gery. Am J Cosm Surg 1987;4:263–267. 279 5. Zocchi ML. Ultrasonic liposculpturing. Aesthet Plast Surg 1992;16:287–298. 6. Zocchi ML. Clinical aspects of ultrasonic liposculpture. Perspect Plast Surg 1993;7:153–174. 7. Zocchi ML. Ultrasonic assisted lipoplasty: technical refinements and clinical evaluations. Clin Plast Surg 1996;23:565–598. 8. Zocchi ML. Basic physics for ultrasound-assisted lipoplas- ty. Clin Plast Surg 1999;26:209–220. 9. Update from the Ultrasonic Liposuction Task Force of the American Society for Dermatologic Surgery. Dermatol Surg 1997;23(3):210–211. 10. Scheflan M, Tazi H. Ultrasonically assisted body contour- ing. Aesthet Surg Quart 1996:16:117–122. 11. Kloehn R. Liposuction with “sonic sculpture”: Six years’ experience with more than 600 patients. Aesthet Surg Quart 1996:16:123–128. 12. Adham MN, Teimourian B, Chiaramonte M. Liposuction using general anesthesia: A plastic surgeon’s viewpoint. In Narins, RS, ed., Cosmetic Surgery: An Interdisciplinary Approach. New York: Marcell Dekker, Inc. 2001:631. 13. Cedidi CC, Berger A. Severe abdominal wall necrosis af- ter ultrasound-assisted liposuction. Aesthet Plast Surg. 2002;26:20–22. 14. Narins RS. Tumescent liposuction. IN Narins, RS, ed., Cosmetic Surgery: An Interdisciplinary Approach. New York: Marcell Dekker, Inc. 2001:550–555. 15. Cook WR Jr. Utilizing external ultrasonic energy to im- prove the results of tumescent liposculpture. Dermatol Surg 1997;23:1207–1211. 16. Cook WR Jr., Cook KK. Manual of Tumescent Liposculp- ture and Laser Cosmetic Surgery. Philadelphia: Lippincott Williams and Wilkins 1999. 17. Klein JA. The tumescent technique: anesthesia and modified liposuction technique. Dermatol Clin 1990;8: 425–437. 18. Havoonjian HH, Luftman DB, Menaker GM, Moy RL. External ultrasonic tumescent liposuction. A preliminary study. Dermatol Surg 1999;23:1201–1206. 19. Mendes FH. External ultrasound-assisted lipoplasty from our own experience. Aesthet Plast Surg 2000;24:270–274. 20. Gasperoni C, Salgarello M. The use of external ultrasound combined with superficial subdermal liposuction. Ann Plast Surg 2000;45:369–373. 21. Rosenberg GH, Cabrera RC. External ultrasonic lipoplas- ty: An effective method of fat removal and skin shrinkage. Plast Reconstr Surg 2000;106:1428–1429. 22. Hu Z, Gao J, Qi X. A comparative study on external ul- trasonic, internal ultrasonic and simple negative pressure liposuction operations under tumescent anesthesia. Zhon- ghua Zheng Xing Wai Ke Za Zhi 2002;18:221–223. 23. Butterwick KJ, Tse Y, Goldman MP. Effect of external ultrasound post liposuction: A side-to-side comparison study. Dermatol Surg 2000;26:433–435. 24. Bernstein G. Ultrasound therapy for postoperative lipo- suction care. Dermatol Surg 1997;23:211. Fig. 40.3. a Prior to procedure. b Two months postopera- tively References Part VII Power-Assisted Part VII Powered Liposuction Equipment Timothy Corcoran Flynn C  41 41.1 Introduction The practice of tumescent liposuction involves refine- ment in technique and improved technology. New equipment is developed almost yearly, and old designs are regularly improved upon and modified. For ex- ample liposuction was initially performed using large (approximately 6–10 mm in diameter) cannulas. Over the years, thinner and thinner cannulas were used with many procedures now being performed using 2–3-mm diameter cannulas. A variety of cannulas are available in different designs, and newer very small cannulas (e.g., 20 gauge) are now available for small areas such as the face. Yet not all new developments are ultimately proven superior. Many authors believe Ultrasound technology was applied to liposuction without any significant improvements. In fact, the use of cannulas outfitted with ultrasound transducer tips was associated with an increased instance of sero- mas as well as cutaneous burns. Most dermatologists have largely abandoned ultrasound technology. One advancement which is a nice addition to the practice of tumescent liposuction is the use of pow- ered instrumentation [1]. This chapter discusses the development and current status of powered liposuc- tion instrumentation. 41.2 Development of Powered Liposuction Technology The concept of using mechanical instrumentation with liposuction technology is actually as old as li- posuction itself. The brilliant surgeons Giorgio and Arpad Fischer introduced the concept of liposuction in combination with instruments they developed, which they called the “cellusuciatome” [2]. The Fisch- ers’ early instruments contained blades with moving internal components designed to cut fat when it was aspirated into the cannula. Later, blunt cannulas were developed with side ports and other designs that as- pirated fat with little blood loss. The idea of powered instrumentation lay dormant. Charles Gross revisited the idea in the 1990s. Using an existing cannula which had an exposed internal blade driven by a motorized handpiece, he modified the instrument for use in fat removal. His “liposhav- ing” procedure was an open technique in which the fat-harvesting unit was used for neck liposuction us- ing submental incisions. Fat cells could thoroughly be removed from the platysma to allow for an even and complete fat extraction. William Coleman, working with the Xomed Cor- poration, furthered ideas in this realm. Other designs explored the use of a rotating blade found within li- posuction cannulas. Experiments revealed that an oscillating system in which the blade made several revolutions clockwise and several revolutions coun- terclockwise worked better than one with continuous unidirectional revolutions. There was a theoretical concern about increased bleeding. It was also found that these techniques tended to occasionally trap fi- brous tissue which could become lodged and restrict blade movements. A few possible complications such as seromas or bleeding from a small varicosity were reported. The oscillating cutting cannulas however did dem- onstrate decreased work on the part of the liposuction surgeon. This led to the development of a number of reciprocating cannula systems. These instruments contained a motor, driven either electrically or by air, which moved the tip of the liposuction cannula for- ward and backward. These designs have been found to decrease the work of performing liposuction on the part of the surgeon and increase the rate of fat re- moval. 41.3 Current Instrumentation Several powered liposuction instruments are current- ly available. Most are driven by electric motors but air-driven models are also available (Fig. 41.1). All of these instruments use motors to drive the cannula in a forward-and-backward motion, assisting the can- nula in removing fat. The author published a paper 284 41 Powered Liposuction Equipment evaluating currently available instrumentation in 2002 [2]. Instruments were assessed clinically by the author, and an independent engineering firm mea- sured each instrument. Laboratory measurements such as the degree of torque, amount of heat produced, size and weight, amount of torque force, and degree of vibration were among the measurements taken by the independent engineering firm. A concise practical description of each instrument was featured. Stroke force was variable, with instruments hav- ing a range of 9.5 30 lb. The noise of the units varied between 60 and 87 dB. Units produced variable heat with surface temperature measurements ranging from 77 to 102°F. Build quality and reliability varied from instrument to instrument. The air-driven devic- es were not preferred by the author owing to clumsi- ness in use and loudness of operation. The cost of the units varied, with Byron’s disposable plastic handles costing as little as US $50 per handle and complete well-built electronic systems such as the Medtronic- Xomed Powersculpt unit costing around US $10,000 (Fig. 41.2). Coleman [3] evaluated the efficacy of powered li- posuction in collaboration with several different au- thors. Liposuction surgeons had been reporting that they felt there was an increased efficiency in fat re- moval. This concept was documented in their study, which looked at liposuction performed by surgeons at four different locations. A variety of electrical and air-driven instruments were used. All cannulas were 3 mm in outside diameter. The amount of fat extracted was measured using a mucous specimen trap, widely used by respiratory therapists, in series between the cannula aspiration hose and the aspirator. The amount of fat aspirated within a 60 second time period was recorded when the cannulas were used in either the “power on” or the “power off” mode. In this study, an overall 30% increase in extraction rate was noticed in the powered versus the non-powered mode. The data were subdivided to indicate that the increased amount of fat extracted was higher for sur- geons who had experience with the powered instru- mentation. For those surgeons who had performed eight or more powered liposuction cases, there was a 45% increase in fat extracted in the powered mode compared with the non-powered mode. As an additional component to the study, patients were queried as to their preference of powered versus non-powered liposuction. Fifty patients responded with 27 (54%) preferring powered liposuction and 23 (46%) not having a preference. Importantly, no patient preferred the non-powered technology. The patients commented on the “comforting” feeling that the vibration gave them during the procedure. In Coleman’s study, differing sties had different improvements in the amount of fat harvested using powered liposuction. The hips demonstrated a 62% increase in extraction rate with the power on. The upper thighs and abdomen exhibited less of a differ- ence with a 48 and a 35% increase in extraction using power, respectively. Katz et al. [4] performed a powered comparison analysis in 21 patients. Powered liposuction was compared with traditional liposuction by perform- ing powered liposuction on one side of the body and traditional liposuction on the contralateral side. True tumescent liposuction was performed using 0.075% lidocaine with 1:1,000,000 epinephrine. For the pow- ered liposuction side, the NuMed powered device was used fitted with a 3- or 4-mm accelerator-type cannu- la. The instrument was set to operate at 5,500 strokes per minute. On the traditional liposuction side, iden- tical cannulas were used without power. Fig 41.1. Two examples of powered liposuction instruments. NuMED’s electric hand piece is shown above, with Byron’s ARC disposable air-driven hand piece below Fig 41.2. The Medtronic PowerSculpt console and hand piece. Note the power cord attached to the electric hand piece and the vacuum aspiration hose attached to the dual side port blunt- tipped cannula 285 Equal amounts of fat and supranatant were har- vested on either side. The study documented that the amount of time taken to perform powered liposuc- tion was 35% less than that for traditional liposuction. Intraoperative pain was 45% less for powered liposuc- tion than for traditional liposuction. Surgeon fatigue was 49% less for powered liposuction than traditional liposuction. Interestingly, at 5 days postoperatively, pain, ecchymosis, and edema were 32–38% less when powered liposuction technology was employed over traditional liposuction. At 2 weeks, pain, ecchymosis, and edema were 27–48% less for the side where pow- ered liposuction had been employed than for the side where traditional liposuction had been used. Patient satisfaction with the results was greater for the side where powered liposuction had been employed than for the side where traditional liposuction had been used; however, the surgeons felt that there were no significant differences between the sides. One seroma was found in the powered liposuction group at 2 weeks and 35 ml of fluid was drained with - out sequelae. The authors commented that their pa- tients found the vibration of the powered liposuction cannula gentler and more relaxing than the shearing sensation of the traditional liposuction cannula. Fodor and Vogt [5] compared their technique of power-assisted lipoplasty with traditional lipoplasty. They felt that the powered liposuction technology was better in the ease of fat extraction. They did not find additional benefit. Fodor and Vogt were using a power cannula, which was driven by nitrogen gas, and having a stroke distance of over 2 mm. This nitrogen-driven instrument is loud and somewhat difficult to control. Perhaps the authors may have found other benefits if they had used the newer electrically operated devices, which are more elegant and easier to use. 41.4 Advantages and Disadvantages Those liposuction surgeons regularly using power instrumentation have found an increased rate of fat harvesting. This makes the performing of liposuction more efficient in that a greater amount of fat can be harvested per given time period. When several cases are performed on the same day, this time-saving is greatly appreciated. There is decreased physical work on the part of the liposuction surgeon. These vibrat- ing systems allow the cannula to move through the tissue with greater ease. The vibration seems to assist the cannula in moving through fibrofatty areas such as male pseudogynecomastia. Patients seem to prefer the comforting feeling of the vibrating cannula, and it may be that the vibratory sensation produces coun- terstimuli that reduce the perception of pain. Disadvantages include the expense of the instru- mentation. Instruments can range from a few thou- sand to up to US $10,000. Some instruments are loud but the well designed more expensive units are fairly quiet when operating. Initial concerns about vibra- tional injury to the hands of the liposuction surgeon have been unfounded. When more than one case is done on the same day, the handle which contains the motor to drive the cannula must be sterilized between use. The author has solved this bottleneck by owning one electronic console and two motorized hand piec- es so that two cases can be performed in one morning or afternoon. 41.5 Summary Powered liposuction technology is a nice addition to the practice of tumescent liposuction. Benefits include decreased work on the part of the liposuction surgeon, increased ease and efficiency of fat harvesting, and a patient’s preference for the comfort of the vibration. It is a nice instrument for difficult fibrofatty areas. The busy liposuction practice can find multiple benefits from the use of powered liposuction technology. References 1. Coleman, WP III. Powered liposuction. Dermatol Surg. 2000 Apr;26(4):315–8. 2. Flynn, TC. Powered liposuction: an evaluation of cur- rently available instrumentation. Dermatol Surg. 2002 May;28(5):376–82. 3. Coleman, WP III; Katz, B; Bruck, M; Narins, R; Law- rence, N; Flynn, TC; Coleman, WP; Coleman, KM. The efficacy of powered liposuction. Dermatol Surg. 2001 Aug;27(8):735–8. 4. Katz, BE; Bruck, MC; Coleman, WP III. The benefits of powered liposuction versus traditional liposuction: a paired comparison analysis. Dermatol Surg. 2001 Oct;27(10):863–7. 5. Fodor, PB; Vogt, PA. Power-assisted lipoplasty (PAL): A clinical pilot study comparing PAL to traditional lipo- plasty (TL). Anesthetic Plast Surg. 1999 Nov–Dec;23(6): 379–85. References [...]... if necessary Breasts: Mercedes- or Rebelo-type cannulas that are 1 5-, 2 0-, or 25-cm long and 3 or 4 mm in diameter Flanks: Mercedes- or Rebelo-type cannulas that are 2 0-, 2 5-, or 30-cm long and 4.0 or 4.5 mm in diameter A Cellulite-type cannula with the same dimensions can be used if necessary Abdomen: Mercedes- or Rebelo-type cannulas that are 2 0-, 2 5-, or 30-cm long and 3, 4, or 4.5 mm in diameter... Mercedes-type cannulas that are 1 5-, 2 0-, or 25-cm long and 3 or 4 mm in diameter A Cellulite-type cannula with same dimensions can be used if necessary Hips: Mercedes- or Rebelo-type cannulas that are 2 0- or 25-cm long and 4 or 4.5 mm in diameter A Cellulite-type cannula with the same dimensions can be used if necessary External thighs: Mercedes- or Rebelo-type cannulas that are 2 0-, 2 5-, or 30-cm long and. .. 4.5 mm in diameter A Cellulite-type cannula with the same dimensions can be used if necessary Internal thighs: Mercedes- or Rebelo-type cannulas that are 2 0-, 2 5-, or 30-cm long and 4 or 4.5 mm in diameter A Cellulite-type cannula with the same dimensions can be used if necessary Knees: Mercedes-type cannulas that are 1 0- or 20-cm long and 3 or 4 mm in diameter A Cellulite-type cannula with the same... Rebelo, Mercedes, and Cellulites, and these may be covered with Teflon or Titaneo Depending on the area, the different types of cannulas used include: – – Submental region: Mercedes-type cannula (15 cm × 3 mm) and Cellulite-type cannula (15 cm × 3 mm) if necessary Arms: Mercedes- or Rebelo-type cannulas that are 2 0-, 2 5-, or 30-cm long and 3 or 4 mm in diameter – – – – – – – – A Cellulite-type cannula... range of conditions and has improved wound healing, reduced edema, and relieved pain of various etiologies The laser used for liposuction is an external-beam cold laser, electric diode, with 63 5-nm wavelength that irradiates adipose tissue at 1.2, 2.4, and 3 .6 J/cm2 [1–5] at 2, 4, and 6- min exposure in each area Samples were taken from abdominoplasty tissues treated with a laser and studied by light... towel Fig 46. 3 Emulsified appearance of the fat following use of the massager prior to liposuction 46. 5 Discussion a b Fig 46. 4 a Bulging abdomen preoperatively b One week postoperatively using external massage-assisted liposuction a b Fig 46. 5 a Fatty flanks preoperatively b One week postoperatively following external massage-assisted liposuction 46. 5 Discussion The use of the massager prior to liposuction. .. Typically, 1-MHz ultrasound heats tissues 2.5–5-cm deep while 3-MHz ultrasound heats tissues that are less than 2.5cm deep Since adipose tissue usually lies over muscle, 43.4 External Ultrasound-Assisted and Power-Assisted Liposuction Safety Using E-UAL and PAL together simultaneously is a topic that will be discussed and debated for years However, close adherence to the existing 2003 Guidelines for Lipo-Suction... tumescent technique for liposuction surgery Am J Cosm Surg 1987;4: 263 – 267 2 Lasswell, M.: As she lay dying Allure, July 1997 3 Illouz, Y-G., Liposuction: The Franco-American Experience Beverly Hills, California, Medical Aesthetics, Inc 1985 4 Fournier, P.F.: Facial contouring with fat grafting Dermatol Clin 1990;8:523–537 5 Illouz, Y.G.: Principles of liposuction In Liposuction: The Franco-American Experience... in emulsification of the fat and a reduction in the force necessary to perform liposuction The cost of a double-headed percussion massager is nil compared with the other equipment that is being utilized to do the same thing With preoperative massage and low-vacuum liposuction, there is less bruising and postoperative discomfort 311 Chapter 47 47 Low-Level Laser-Assisted Liposuction Rodrigo Neira 47.1... G: Vibration assisted liposuction (VAL) in tumescent local anesthesia (TLA) In: Skin and Environment- Perception and Protection 10th EADV (Eur Acad Derm Venerol) Congress, Munich 2001 Bologna, Monduzzi 2001 13 Sattler G, Sommer B: Tumescent liposuction in Germany: History and new trends and techniques Dermatol Surg 1999;25:221–223 Chapter 46 External Percussion Massage-Assisted Liposuction Melvin A . with lipoplasty, and (6) using careful pre- operative and postoperative monitoring [1]. 43.4 External Ultrasound-Assisted and Power-Assisted Liposuction Safety Using E-UAL and PAL together. 1 5-, 2 0-, or 25-cm long and 3 or 4 mm in diam - eter. – Flanks: Mercedes- or Rebelo-type cannulas that are 2 0-, 2 5-, or 30-cm long and 4.0 or 4.5 mm in diameter. A Cellulite-type cannula with the. are 1 5-, 2 0-, or 25-cm long and 3 or 4 mm in diameter. A Cellulite-type cannula with same dimensions can be used if necessary. – Hips: Mercedes- or Rebelo-type cannulas that are 2 0- or 25-cm