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by El Hassane TAZI M.D.
tazilipo@iam.net.ma
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An Endomicroscopic comparison of various techniques and technologies of Lipoplasty
 
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Abstract

This study on an endomicroscopic comparison producing video-images of lipoplasty is not only directed to how to extract fat, but also how to preserve all the systems surrounding it which, in our point of view, improve the quality of the results obtained and sought by both our patients and ourselves.
It has two objectives. Firstly, it determines the limitations of all lipoplasty techniques (their advantages and disadvantages) and mainly the possibility of combining them to take advantage of every one and also to minimize their disadvantages. Secondly, it also determines their limitations in order to substitute the open surgery which used to be unavoidable.
Consequently, the endomicroscopic exploration of the subcutaneous fat, while practicing different techniques of Ultrasound Assisted Lipoplasty, shows how the total respect of the physical principals (cavitation and microstreaming) of ultrasound energy is safe and efficient. This respect is related to the use of the adapted probe (solid or hollow) to the subcutaneous fat which can preserve its precious surrounding stuctures (conjunctive fibres, vessels, nerves and lymphatics) in order to be able to suck a large volume of liquidized blood free fat and to keep a tightened skin.

Introduction

Women no longer want to keep round abdomens as a sign of neglecting themselves, but rather they seek to keep flat ones as a sign of their adaptation to a younger and dynamic society. The lipoplasty surgery is the surgery of the physical appearance, which could be harmonized by remaining discreet, natural and attractive. It does not take account solely of the society where we live, the mediatic pressures or modes, but mainly of the deep desire of each person.
The endomicroscopic method, which has been introduced to the lipoplasty sphere, has opened new horizons which could be explored so as to attain better control of the various technologies and techniques and to bring for the plastic surgeons' hands the best and harmless instrument to sculpt the body of our patients. These technologies and techniques are intimately related and their comparisons are related as well.

The lipoplasty technologies and techniques have known several important evolutions during the last two decades.This innovation, that is mostly practiced in the world, explains the physicians' infatuation for this technique.
Yves Gerard Illouz M.D from France has introduced in 1977 the liposuction that is currently the first operation in aesthetic surgery in the world(8). Then, Pierre Fourinier M.D from France has also developed in 1985 the liposuction with the syringe (Lipojet). And Michel Zocchi M.D from Italy has developed later in 1988 a technique of Ultrasound Assisted Lipoplasty (UAL hence forth).

Methods and Materials

A- Patients
The author presents his experience using different technologies and techniques of lipoplasty analysed by endomicroscopy of more than 1000 patients over a period of six years.
Statistically, we derive the following information from this population :
  1. Sex: 95% of these patients are women, and 5% are male.
  2. Age: The women's age ranges from 20 to 65 years old, and that of men varies from 20 to 55 years old.
  3. Localisation:
    - Abdominal area and hips alone 55%.
    - Thighs 25%.
    - Neck and chin 5%.
    - Calves and ankles 5%.
    - Buttocks 5%.
    - Bilateral gynecomastia alone 2%.
    - Combined with open surgery (Abdominoplasty, Mammoplasty, Rhytidectomy) 3%.
  4. Weight: The women's weight varies from 50 kg to 125 kg, and that of men varies from 60 kg to 130 kg.
  5. Fat removal in a single session with UAL technique: This varies from 500 cc to 12000 cc.

B- Means of exploration

The in vivo endomicroscopic method, which studies and shows objectively the safety and efficiency of the lipoplasty machines rather than approaching them subjectively, is currently the best live and visual witness today.
The author's work and analysis, which are based on stretched hundred-hours of video endomicroscopy and thousands of images analysed by the computer, still neccessitate a more intensive approach by a qualified professional team.
These video-images have been achieved by experts at a professionally high level (endomicroscope, beta-cam video, professional computer... ). They are taken in real time during surgery and shed a new light on the lipoplasty technique ( Diagram 1 )

 

Clinical Intruments
UAL SAL EUAL
     
Endoscopic Equipment
 
Digital Equipment   Beta Video Equipment
     

C- Technologies used in this comparison

1 - UAL ( Internal Ultrasound ) :

  • a) The physical principals are:
    • Cavitation, microstreaming and emulsification.
  • b) A generator frequency from 20 to 30 KHZ.
  • c) The probes are:
    • -Titanium or Stainless steel.
      - Solid or hollow( tip or laterale ).
      - Irrigation or cooling sheath.
      - Aspiration.
  • d) Control ( foot or hand ).
2 - External Ultrasound ( EUAL) :
  • a) The physical principals are:
    - Cavitation, no microstreaming and no emulsification.
  • b) Frequency 1MH ( pulsed or continuous ).
  • c) Ultrasound applicators (transducers).
3 - Suction assisted lipoplasty ( SAL henceforth )
  • a) Vacuum.
  • b) Cannula diameter.
  • c) Holes (size and border).

4 - The comparison could be presented graphically in the following table (n°1) :

  UAL SAL EUAL
  Solid Hollow Traditional Tumescent Suction Adjuvant
             
Cavitation +++++ +++ - - ++ +
Microstreaming +++++ +++ - - ? ?
Probe apex surface ++++ ++ - - - -
Cutting hole edge - +++ ++ ++ ++ -
Cost ++ +++ + + ++ ++
Cannula life ++++ +++ Long Long ? ?
Emulsification ++++ +++ No No No No

The vibrating frequency of ultrasound energy is transmitted to the whole probe between 20 000 and 30 000 cycles per second given one variant amplitude ranging from 20 to 180 microns according to the power of each ultrasound machine. Notice that each edge or hole of the probe will have the same phenomenon.
The efficiency of the ultrasound energy is more related to the amplitude generator power and to the surface of the tip of the probe ( solid or hollow, square-end or round-end) than to the frequency and the material of the probe which is made of titanium or stainless steel ( FIG. 2 & 3).

D - Objectives of this study:
The endomicroscopic method, that is introduced in the lipoplasty sphere, opens new horizons which should be explored so as to attain better control of the various techniques and also to bring to the plastic surgeons' hands the best instrument to sculpt the body of our patients.
So, the author's curiosity has been directed towards not only how to extract fat, but how to preserve all the systems surrounding it which, according to his point of view, improves the quality of the results obtained and sought by both our patients and ourselves.
The endomicroscopic comparison has two objectives:
The first objective is to determine the limitations of all lipoplasty technologies and techniques (their advantages and disadvantages) and mainly the possibility of combining them to take advantages of every one and also to minimize the disadvantages.
The profit of the in vivo criteria for the work with different machines determines the ultrasound assisted lipoplasty today and also how the machines should be in the future.
The second objective is to determine the limitations of the lipoplasty technologies and techniques in order to substitute the open surgery, which used to be unavoidable.

RESULTS AND DISCUSSION

The issues that will be demonstrated and discussed in this chapter are the following:
- The anatomical structure of the subcutaneous fat .
- The wetting effect on the fat .
- The application of ultrasound energy with the solid or hollow probe technique.
- The traditional lipoplasty technique .
- The application of external ultrasound.
- The large volume aspiration.
- The post operative time.
- The comparison between the lipoplasty techniques.
- The advantages and disadvantages of the different techniques.
A- An anatomical approach through the Endomicroscope.
The visualisation of the different structures of a subcutaneous tissue consists of the following:
the dermis, the subdermal tissue, the conjunctival tissue, the blood vessels, the vascularized fat and the magnification of fat cells. ( FIGS. 4-12 )
The subcutaneous fat is a precious tissue, and it is necessary to preserve its valuable characteristics.
The important thing is not what we remove but what we leave between the skin and the fascia muscle.
B- Wetting / Infiltration
 
The Wetting is an inevitable stage of lipoplasty. It is an intratissuelar fluid expansion (FIG.12&13), and should cause a tightened fluid distention of the fatty tissues. The subcutaneous fat (its superficial and deep layers) must be homogeneously infiltrated. An adequate wetting (superwet) is reached by the infiltration up to 1 cc of saline solution containing the epinephrine and lidocaine per each aspirated cc .
Clinically, an effective wetting is reached when the skin becomes pale or white due to both the fluid pressure and epinephrine effect. Thus, it becomes hard or impossible to do the pinch-test as the tissues buldge ( FIG. 13, A ).

Whereas endoscopically, an appropriate wetting is reached when a spongy fragmentation of the fat, a vasoconstriction and a conjunctival distention are apparent ( FIG. 14 ).

According to our point of view, we do not think useful to multiply the incisions to process the treatement of the same area. An even incision can be applied to different sculpture areas (eg, the external and internal sides of the thigh in a ventral position) which necessitate putting a skin protector before using the UAL technique if this does not use an irrigating or a cooling sheath (FIG.15).
C- Traditional Liposuction
Endoscopically, the aspiration through the hole of SAL cannula aided by a vaccuum shows that it does not make any difference between the fatty tissues and all the other precious surrounding structures ( FIG. 16 & 17 ).
This tendency of the SAL cannula depends more on the size and edge of the holes than on the diameter size of the cannula ( FIG. 18 ). The sliced edge of each cannula hole will be responsible for destroying the precious subcutaneous structures (blood vessels, lymphatics, nerves...).Therefore, this phenomenon constrains the aspirated volume of fat in order not to run the risk of losing a lot of blood ( FIG. 19 & 20 ).
The more we know about the cannula that is thin with small diameter holes and a powerless pressure of the vacuum cleaner, the more the approach to the surface of the subdermal layer is possible and efficient in the expert surgeons' hands ( FIG. 21 ).
D- Ultrasonically Assisted Lipoplasty with various machines.
1- The application of Ultrasound energy to the subcutaneous fat with the solid probe technique.
UAL has been introduced and developed in Italy by Michele Zocchi M.D. This technology uses a machine that transforms electrical energy into high frequency sound which is then transmitted through a hand-piece into mechanical vibrations emitted at the tip of a solid titanium probe. Thus, this ultrasound energy has three effects: micromechanical, thermal and cavitation .

The physical principals of the internal ultrasound energy result in:
- molecular hyperagitation ( FIG. 22,A ),
- Cavitation ( FIG. 22,B ),
- Microstreaming ( FIG. 23,A ),
- Selective destruction of adipocytes ( FIG. 23,B & FIG. 24 ),
- Emulsification ( FIG. 25 ).
The UAL, which liquidizes the fat in its site by a cavitation phenomenon, yields the formation of bubbles of gaz and their implosion gives a microstreaming of how to disrupt membrane cells (FIG.22,B).
The physical order of the cavitation effect together with the microstreaming one entail the destruction of fat cells. While they preserve a vasculonervous system, there exists a real balance between the cavitation effect and the thermal one ( FIG. 23,A ). When the deep layer of the subcutaneous fat is infiltrated, the cavitation effect sought prevails on the thermal one which should be avoided, and vice versa.
It is essential and crucial that the fat is infiltrated with a wetting solution prior to begin UAL because it enhances the cavitation effect. Notice that the probe must be constantly in slow motion all the time. The technique must be gentle and requires great care without any manual force, however it is time-consuming and tedious. It takes, in general, more time that would have been necessary to treat the same amount of fat deposit using SAL in areas of large fat deposit as a longer utrasonic treatment is required.Therefore, one needs to spend more time gliding the probe through the fatty tissues. The solid titanium probe preserves the nerves as well as the arteries and veins that cross the fatty tissue     ( FIG. 27).
The ultrasound probe introduced through a skin incision will glide effortlessly through the subcutaneous fat when the energy is applied. Then, the contact of the probe tip with the fatty tissue produces a cavitation phenomenon which will destroy inwardly the membrane of the adipocytes and will emulsifate them. Therefore, the fatty emulsion is easily aspirated ( FIG. 26 ). The cleaning of the emulsified fat completes the first gesture of ultrasound energy by aspirating this liquidized fat with a low pressure and a cannula of 3 or 4 mm during the same operation session. While both the Ultrasonic treatment and the aspirative stages require essentially no physical force, the motions become slow, elegant and time-consuming ( FIG. 26,B ).
Sometimes the application of the solid titanium probe under the dermis will end the treatment of lipoplasty in order to well-harmonize the skin aspect. Nevertheless, applying statically any internal ultrasound energy to dry dense tissues like a skin can cause themal burns.
In some cases, the final remodeling of UAL by a roller, an endermology or an equivalent technique is essential because it helps evacuate all the serosity and emulsion made by the cavitation of the ultrasound that sometimes even a lipo-aspiration cannot evacuate. The remodeling technique is able to reduce edema and poste-operative bruises or even to avoid using the evacuation drainage (FIG.27 & 28).
The utilization and perfect manipulation of the UAL must necessitate training in workshops by specialized plastic surgeons to avoid corporal damage. This is considered a powerful instrument that can be very harmful when it is badly used, hence the need to observe some rules that are pertinent to this technology, like the use of the ultrasound energy that necessitates to work dynamically and not statically in order not to run the risk of eventual burn-attacks .
2- The application of Ultrasound energy to the subcutaneous fat with the hollow cannula probe technique .
The ultrasound machines that liquidize and suck at the same time have been developed in the United States, France and South America. While conceptually those machines could have reduced the operative time to half the time of SAL since the authors (El Hassane Tazi M.D and Michael Scheflan M.D) have already tested a machine that aspirates one liter per ten minutes, which is not totally liquidized, they tend to be sometimes ineffective, unreliable and inconsistent when they are applied under the skin ( FIG. 29 ).

The vibrating frequency of ultrasound energy is transmitted to the whole hollow probe and its edge hole between 20 000 and 30 000 cycles per second given one variant amplitude ranging from 20 micron to 180 micron according to the power of each Ultrasound machine. Therefore, the more the edge is sliced and combined with aspiration, the more the precious subcutaneous structures (blood vessels, nerves and hymphatics) will be destroyed. Concequently, the aspiration combined with ultrasound energy hinder the right progress of the physical principals of ultrasound energy (cavitation, microstreaming and emulsification) ( FIG. 29, 30 & 31 ).
The edge of the hollow probe, which is able to destroy subcutaneous structures on its passage and which is similar to the cutting solid probe ( FIG. 2 ), is increased dramatically by the frequency and amplitude of ultrasound energy that is worsened by aspiration.
According to the physical principals of all ultrasound technology, the hollow probe must be used far from the skin in order to preserve all the thin subdermal structures ( FIG. 31 ).
E- The intraoperative application of external ultrasound
Endoscopically, the static and permanant application of the external ultrasound at a minimum of 5 sec in the same area shows intraoperatively the production of gaz bubbles after the wetting stage. Some of them are cavitated with neither any evidence of microstreaming, nor any emulsification; however, some fatty drops appear eventually. This application may probably assist the dispersion and migration of the wetting solution between the fatty lobules or the fat cells and the disruption of the collagen fibers which are still non approved ( FIG. 32, 33 & 34 ). There exists a real balance between the cavitation effect, which necessitates a constant application of energy, and the thermal one which runs the risk of eventual burn-attacks.
F- The large aspirated volume .
The most drastic diet cannot eliminate all the time the significant resisting excess of fat deposit on the thighs, hips, abdomen and the nape. But, women, worrying about their health and silhouettes, are conscious of how to lose the excess of fat deposit. Therfore, the large aspirated volume aims at liberating the body of weight and to give it a chance to be fit.
The aspirated volume by SAL varies from 500 cc to 3000 cc in one session(1 liter per 15mn); using the tumescente technique the volume varies from 500 cc to 5000 cc(1 liter per 12 mn); whereas with the use of UAL, one can evacuate easily a volume varing from 500 cc to 10000 cc (1liter per 20 mn) ( FIG. 35 ).
We think that the quantity of a large aspirated volume of lipoplasty depends on:
-the total aspirated volume in each session,
-its variation from 6% to 12% of body weight,
-its variation from 30% to 60% of the body surface treated.
-the time-consuming peroperatively is still important.
By doing so, the largely aspirated volume cannot only benefit the silhouette, but the health as well.
G - The postoperative care
- Immediate:
We observe that the immediate postoperative care following the UAL technique is highly less significant than that after the SAL as long as it certainly yields better results, less edema and bruises.Whereas, the resumption of the activity can be made up to the third or fourth day after the operation with a feeling of stiffness. So, there often exists some edema and bruises that disappear in the following few weeks; and based on our endomicroscopic analysis ( FIG. 36,B ) done with Peter Fodor M.D , the author advises his patients to undergo some sessions of endermology massage and EUAL technique   ( FIG. 36,A ) as follows: endermology in 15 minutes followed by EUAL in 10 minutes and ended by endermology in another 15 minutes. The final result expected will appear between one and two months after the operation during which the patients should wear the adapted garments.
- Long term:

We also observe that with the use of UAL, the quality of skin retraction is still stable and effective over a period of 6 years even on areas that are considered taboos according to the SAL.

COMPARISON BETWEEN VARIOUS TECHNOLOGIES AND TECHNIQUES OF LIPOPLASTY AND THEIR PRACTICAL APPLICATIONS

A- Comparison between UAL and SAL.
In this context, the author compares with his colleague, who has high experiences of SAL, two techniques namely, UAL and SAL which are respectively practiced simultaniously on each half of the same patient's abdomen preceded by the same infiltration. This evalution has been made in the presence of other colleagues. Consequently, after the stagnation of the total amount of the aspirated fat taken from the two halves of the abdomen, the results show, firstly, that the aspirated volume done by the UAL technique is highly more significant than that done by the SAL one. Secondly, the amount of the aspirated fat part done by the former is greater than its counterpart done by the latter. Thirdly, the amount of the aspirated bloody liquid part done by the former is less than its counterpart done by the latter. The result also shows that the punch-test applied to the area treated by UAL is thinner than its counterpart treated by SAL ( FIG. 37 ).
Additionally, we observe per-operatively by endomicroscopy that the precious structures (conjunctive tissues, nerves and lymphatics) are more preserved by UAL ( FIG. 28,B) than by SAL ( FIG. 17,B). A year later, the skin retraction of the abdomen is stronger and more regular in the UAL area than in the SAL one. Hence, this necessitates a complementary reduction of fat in the above-mentioned SAL area.
B- Comparison between UAL and EUAL.
The Author also compares the intraoperative application of the solid titanium probe versus external ultrasound to the subcutaneous fat of the same patient under the same conditions mentioned above.
Consequently, the physical principals of UAL and EUAL ( FIG. 32 ) show endomicroscopically that the sole common phenomenon is the production of gaz bubbles, but EUAL does not produce any microstreaming which is the most important stage entailing fat emulsification that we find with UAL. However, we observe that some oil drops float on the infiltrated liquid. So, the SAL that follows the EUAL leads to an easy aspiration of fat with less blood loss.
C- Comparison between the superwet and tumescente techniques ( FIG. 14 ).
The other comparison has been done between the 'superwet' (in a ratio of 1 cc infiltrate to 1 cc aspirate)( FIG. 15,A) and tumescent techniques (in a ratio of 2 or 3 cc infiltrate to 1 cc aspirate) ( FIG. 15,B) on the same patient under the same conditions mentioned above.
Consequently, the first one produces a hyperdistension and tension of conjunctival tissues leading to a separation of fat lobules.Whereas the second one produces a distension and separation of conjunctival and fatty tissues to their maximum of resistance which result in the destruction of some of them .However, after the liposuction, the tumescente technique entails a greater aspirated volume (in order to obtain the same punch-test on both sides) and less blood loss than its counterpart (the superwet technique). In spite of all that, there still exists the major systemic risk along with the tumescente technique.
The Comparison is presented in Table 2 :
  UAL SAL EUAL
  Solid Hollow Traditional Tumescent Suction Adjuvant
             
Volume aspirates +++++ +++++ +++ ++++ +++ -
Skin tightening +++++ +++ +++ +++ +++ ?
Ecchymosis ++ +++ ++++ +++ +++ -
Discomfort ++ ++ +++ +++ +++ ++
Irregularity +/- + +++ ++ ++ -
Better result Faster Faster Slower Slower Slower Faster
Blood loss + ++ +++ ++ ++ -
Operative time +++ ++ + ++ ++  
Sculpturability ++++ +++ ++ ++ ++ +
Surgeon fatigue + + ++ ++ ++ +
Skin necrosis + ++ ++ + + ?
Skin burn ++ ++ No No +++ +++
Seromas ++ +++ ++ ++ ++ -
Incisions ++ ++ + + + -
Complementary SAL +++ ++ Total Total +++ -
Skin protectors + + No No No No
Selectivity ++++ ++ ++ ++ - -
Specificity ++++ +++ ++ ++ - -
Safety and reliability +++ ++ ++++ +++ + +
D- Clinical Applications
Video image analysis of UAL demonstrates the following:
1. Easy case (no open surgery indication):
All techniques give similar results.
2. Intermediate case (open surgery indication):
UAL aided by aspiration helps avoid open surgery at 80%.
3. Difficult cases (with or without open surgery indication):
Abdominal tension by excess of fat deposit: the UAL aided by aspiration helps to avoid open surgery.
Moderately slackened skin of the abdomen:
The adequate use of UAL helped by aspiration may avoid open surgery or delay it by 6 months to 1 year, with a simple excision of skin excess.
The loosely slackened skin of the abdomen resulting from pregnancy or significant weight fluctuation: Open surgery cannot be avoided; only abdominoplasty can resect all the skin excess, with a resultant long scar.
Irregular skin aspects after traditional liposuction: The correct superficial application of UAL with the solid probe can harmonize these.
Lipoplasty, particularly UAL, is still an ideal technique in aesthetic surgery, an innovation that leaves practically no large scars.
Lipoplasty surgery is meant to harmonize and not to transform, and is not a replacement for a healthy diet or adequate exercise.

CONCLUSION

 
Basing on the anatomical approach and the analysis of the different techniques, the technology of U.A.L today has the following advantages over traditional liposuction. It provides large volumes of fat aspirates in a single session. It also produces blood free aspirates and induces remarkable skin envelope tightned by retraction and contraction. Similarily, it is potentially less tiring, improves sculpturability and decreases the surgeon's fatigue.
Given the following disadvantages of UAL which are: long tedious operations (three stages procedure: wetting, melting and suction), increasing potential complications and having a long learning curve with a risk of skin burn or skin necrosis, this current technology still necessitates, in our opinion, to be ameliorated. The reason behind is that the improved future machines of U.A.L must exclude the serious disadvantages of both traditional and Ultrasonic techniques while adapting and improving their advantages which will be able to change the art and science of body countouring.
The production of UAL machines in the future must acquire the following advantages in addition to the above-mentioned ones:
- A short learning curve.
-One or two stages procedure:(wetting and melting combined with aspiration).
-Safe, reliable and efficient.
-Enhancing the advantages of cavitations.
-Reducing the thermal effect.
-Destroying selectively only the fatty tissues.
-Avoiding nerve injuries.
-Reducing the operating time in comparison with SAL or actual UAL.
-Reducing the surgeons' fatigue.
-Enhancing sculpturability.
-Aspirating a large volume of emulsified fat with high security.
-Achieving fastely better results.
Actually, the author can predict that when these technological goals are met, the future new machine using ultrasound energy will be able to substitute traditional liposuction.

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