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Comparative Analysis of Blood Loss
in Suction-Assisted Lipoplasty and
Third-Generation Internal
Ultrasound-Assisted Lipoplasty
Onelio Garcia, Jr, MD; and Nirmal Nathan
Background: Lipoplasty remains the most common cosmetic surgical procedure performed in the United
States. In spite of its well documented clinical advantages, ultrasound-assisted lipoplasty (UAL) accounts for
less than 20% of all lipoplasty procedures currently performed.
Objective: The purpose of this study is to determine the blood content of third-generation internal UAL aspirate and compare it to traditional lipoplasty aspirate.
Methods: The lipoplasty aspirate of 27 consecutive patients who underwent traditional suction-assisted
lipoplasty (SAL) of their back and posterior flanks was compared to the aspirate of 30 consecutive patients who
underwent third-generation internal UAL of their backs and posterior flanks using the VASER Internal
Ultrasound Device (Sound Surgical Technologies; Louisville, CO). The volume and composition of the wetting
solution used was the same for both groups. The aspirate analysis was performed by an independent laboratory on a Beckman Coulter LH 750 blood analyzer (Fullerton, CA) and consisted of complete blood counts
after separation of the fat.
Results: The hemoglobin content of SAL aspirate was 7.5 times greater than in the aspirate. The hematocrit
value of SAL aspirate was 6.5 times greater than in the VASER-assisted lipoplasty aspirate. Statistical analysis
using an independent t test confirmed that the data was statistically significant with P values of < .0001 for both
hemoglobin content and hematocrit values.
Conclusions: We conclude that third-generation internal UAL should be considered for patients undergoing
large-volume lipoplasty procedures or lipoplasty of tight, fibrous areas, such as the back and posterior flanks,
where increased blood loss is expected. (Aesthetic Surg J 2008;28:430–435.)
ccording to the American Society for Aesthetic
Plastic Surgery, lipoplasty remains the most common cosmetic surgical procedure in the United
States, with more than 400,000 procedures performed in
2007.1 In spite of its well documented clinical advantages,2–8 ultrasound-assisted lipoplasty (UAL) is currently performed in only 17.4% of lipoplasty cases.1 Several
factors, such as additional costs,9 increased surgical
time,2,4,10 technical difficulty with a steep learning
curve,11 greater potential for complications,2,12–14 and
complex machinery and instrumentation certainly play a
role in the infrequent use of UAL in body contouring.
The introduction of third-generation internal ultrasound
A
Dr. Garcia is voluntary Assistant Clinical Professor, Division of
Plastic Surgery, Department of Surgery, Miller School of Medicine,
University of Miami, Miami, FL. Mr. Nathan is a research assistant in the same division.
430 • Volume 28 • Number 4 • July/August 2008
devices has addressed many of the drawbacks associated
with the early UAL devices; however, in spite of the well
documented clinical efficiency and safety of the new
devices,5,15 the use of UAL has decreased almost 4%
since 2005.16
When first introduced in this country, “dry lipoplasty” was associated with blood loss of 20% to 45% of the
volume aspirated.17,18 The use of epinephrine-containing
wetting solutions decreased blood loss to 8% to 30% of
the aspirated volume.18,19 The introduction of the superwet technique, using a 1:1 ratio of infiltrating solution to
aspirate, and the tumescent technique, which required
up to a 3:1 ratio of infiltrate to aspirate, significantly
lowered the blood loss associated with these procedures
to a single-digit percentage of the aspirate volume.20,21
The use of UAL further decreased blood loss in the aspirate,3,22–24 and it has been recently documented that
third-generation internal UAL yields even a cleaner aspiAesthetic Surgery Journal
rate, with a higher percentage of supernatant fat.5,15 The
purpose of this study is to document the blood content
of third-generation internal UAL aspirate and compare it
to the blood content of traditional suction-assisted
lipoplasty (SAL) aspirate.
METHODS
Twenty-seven consecutive female patients ranging in age
from 18.75 years. to 54.5 years (average age, of 33.3 yrs)
underwent SAL that included contouring of their back
and posterior flanks. The patients in this group had a
body mass index (BMI) range of 18.8 to 30.1, with an
average BMI of 24.3. The volume of wetting solution
used was approximately a 1:1 ratio of infiltrate to aspirate and consisted of 1 mg of epinephrine 1:1000/liter of
normal saline. There was approximately a 15-minute
interval between the infiltration of the wetting solution
and the suction phase to allow for the vasoconstriction
effects of the epinephrine to take place. Mercedes-type
lipoplasty cannulas (3.5 mm and 3 mm) were used, and
general anesthesia was used in all cases. The aspirate
corresponding to the back and posterior flank lipoplasty
was kept separate and sent for analysis. The total volume of aspirate ranged from 1250 mL to 5250 mL (average, 3366 mL). The back and posterior flank portion of
the aspirate volume ranged from 450 mL to 1400 mL
(average, 768 mL).
Thirty consecutive female patients ranging in age
from 18.5 years to 70.3 years (average age, 41.9 yrs)
underwent third-generation internal UAL using the VASER device (Sound Surgical Technologies, Louisville, CO).
The BMI range in this group was 19.6 to 33.7 (average
BMI, 25.6). All cases included lipoplasty of the back and
posterior flanks, and the aspirate corresponding to those
anatomic areas was kept separate and sent for analysis.
A
The total volume of aspirate ranged from 1600 mL to
9200 mL (average, 5755 mL). The portion of aspirate
volume corresponding to the back and posterior flanks
ranged from 800 mL to 4200 mL (average, 2450 mL). For
the purposes of this study, the wetting solution used also
consisted of 1 mg of epinephrine1:1000/L of normal
saline at a 1:1 ratio of infiltrate to aspirate. (We typically
use a ratio of 3:1 infiltrating solution to aspirate.) There
was also an approximately 15-minute interval following
the infiltration of the wetting solution to allow for the
vasoconstriction effects to take place. For the purposes
of this study, the amplitude setting on the device was
90% continuous VASER mode applied for approximately
1 minute per 100 mL of infiltrating solution used. (Our
usual VASER times are approximately 50% to 60%
longer). The VASER probes used were mainly 3.7-mm 2ring and 2.9-mm 3-ring. VentX cannulas (3.7- and 3.0mm; Sound Surgical Technologies) were used in all of
the VASER-assisted lipoplasty (VAL) cases. All cases
were performed under general anesthesia. Informed consent was obtained from all patients in both the SAL and
VAL groups.
The aspirate from the back and posterior flanks was
chosen for analysis because these are tight, fibrous,
anatomic areas that are associated with greater blood
loss during lipoplasty procedures (Figure 1). The aspirate analysis consisted of complete blood counts after
separation of the fat. This was performed by an independent laboratory on a Beckman Coulter LH 750 blood
analyzer (Fullerton, CA). Normal values on this analyzer
are 12 to 16 gm/dl for hemoglobin and 37% to 47% for
hematocrit. Because the main purpose of the study was
to document and compare blood loss in the lipoplasty
aspirates, only the hemoglobin and hematocrit values of
the complete blood counts were evaluated.
B
Figure 1. A, Typical bloody suction-assisted lipoplasty aspirate from back and posterior flanks. B, Typical VASER-assisted lipoplasty aspirate from
back and posterior flanks. Both the aspirates are approximately the same volume; however, the VASER-assisted lipoplasty aspirate is typically
cleaner and contains a higher percentage of supernatant fat.
Blood Loss in SAL and Third-Generation Internal UAL
Volume 28 • Number 4 • July/August 2008 • 431
RESULTS
The hematocrit values for the SAL aspirate ranged from
2% to 7.2% (mean, 3.98%) compared to the VAL aspirate, which had a hematocrit range of 0.3% to 1.1%
(mean, 0.61%). The hemoglobin content of the SAL
aspirate ranged from 1.2 to 3.4 g/dl (mean, 2.23 g/dl).
By comparison, the hemoglobin content of the VAL aspirate ranged from 0.01 to 0.9 g/dl (mean, 0.3 g/dl). The
complete raw data is shown in Table 1. The mean hemoglobin content of SAL aspirate was 7.5 times greater
than in the VAL aspirate. The mean hematocrit value for
SAL aspirate was 6.5 times higher than in the aspirate
from the VAL group. VAL yielded a more consistent aspirate with significantly less dispersion of both hemoglobin and hematocrit values, as depicted in Figure 2. The
data were subjected to an independent t test for statisti-
Table 1. Raw data of study group
Patient
Hematocrit (%)
Hemoglobin (g/dl)
SAL
Age (yr)
VAL
SAL
VAL
SAL
VAL
SAL
VAL
SAL
VAL
1
39.75
42.3
3650
5600
1000
2200
2
0.7
1.8
0.2
2
37.5
48.5
3000
5450
800
2000
2.4
0.6
2
0.6
3
31
34.75
2850
6800
700
2850
2.4
0.4
1.4
0.1
4
42.3
18.5
2600
3600
650
1200
3.2
0.7
1.2
0.2
5
20.5
21
3250
4250
700
1950
2
0.5
1.3
0.1
6
28.75
29.8
4100
6600
950
2800
2
0.5
2
0.2
7
24.3
42.5
4450
7450
700
3450
3.5
0.7
3.4
0.2
8
19.5
47.6
1800
4900
500
2300
7.2
0.5
2.7
0.1
9
49.1
24.3
3100
6200
650
2500
4
0.5
1.4
0.7
10
30.9
56.75
4750
5150
900
2200
2.3
0.7
2.4
0.1
11
36.5
19.5
4250
3450
800
1250
4.5
0.8
3
0.1
12
41.3
46
3900
6000
650
2300
5.5
0.4
1.8
0.2
13
34.75
70.3
1600
3850
450
1450
3
0.5
2.1
0.7
14
54.5
36.9
3950
9200
700
4000
4.5
0.9
2.2
0.1
15
38.3
48.5
4400
4800
1100
2050
4.2
0.9
2.3
0.2
16
22.2
62.1
1250
3000
450
900
4.8
1.1
1.8
0.2
17
32.2
57
4700
4600
1400
2150
3
0.8
2.8
0.4
18
39
41.3
5250
8400
1250
3650
5.5
0.5
2.9
0.1
19
43.5
49.75
3400
5000
650
2200
4.9
0.5
2.7
0.1
20
23.75
20.25
2200
5750
600
2250
4.1
0.5
1.9
0.2
21
28
63.9
3950
1600
800
800
5.2
0.7
2.8
0.8
22
18.75
47.25
2450
6050
700
2800
6.7
0.3
3.2
0.2
23
40.25
31.1
4000
8750
850
4200
4.7
0.8
2.7
0.2
24
27.8
60.5
4900
4800
1200
1800
3
0.3
1.8
0.9
25
21.2
30.9
2150
8400
500
3950
4
0.6
2.2
0.1
26
48.5
29.8
1800
7750
450
3700
4.9
0.5
2.4
0.3
27
25.3
50.5
3200
6100
650
2350
4.1
0.6
2
0.2
28
—
47.5
—
5500
—
2250
—
0.3
—
0.1
29
—
22.3
—
8250
—
3800
—
0.8
—
0.6
30
—
58
—
5400
—
2200
—
0.6
—
0.8
—
90,900
172,650
20,750
73,500
107.6
18.2
60.2
3366
5755
Total
—
Mean
33.3
Total aspirate (mL)
41.97
Back/flank aspirate (mL)
768.5
2450
9
3.98
0.61
2.23
0.3
Variance
1.949
0.0372
0.3483
0.0648
SD
1.3961
0.1929
0.5902
0.2546
SAL, suction-assisted lipoplasty; SD, standard deviation; VAL, VASER-assisted lipoplasty.
432 • Volume 28 • Number 4 • July/August 2008
Aesthetic Surgery Journal
B
A
Figure 2. A, Significant differences in hemocrit values between suction-assisted lipoplasty and VASER-assisted lipoplasty. B, Significant differences
in hemoglobin content of the aspirate between suction-assisted lipoplasty and VASER-assisted lipoplasty. Note the consistency of VASER-assisted
lipoplasty aspirate and the significant dispersion of values in the suction-assisted lipoplasty aspirate.
A
B
C
Figure 3. A, Preoperative view of a 49-year-old woman. B, Postoperative view 48 hours after 3100 mL total aspirate was removed by suctionassisted lipoplasty. C, Postoperative view 60 days after suction-assisted lipoplasty.
A
B
C
Figure 4. A, Preoperative view of a 39-year-old woman. B, Postoperative view 48 hours after 5250 mL total aspirate removal with suction-assisted lipoplasty. C, Postoperative view 75 days after suction-assisted lipoplasty.
cal significance. The t score for the hematocrit values
was ⫹13.13 and for hemoglobin +16.31, with P < .0001
for both hematocrit and hemoglobin, confirming that the
data were highly statistically significant.
Blood Loss in SAL and Third-Generation Internal UAL
The back and posterior flanks have traditionally been
associated with a high degree of ecchymosis in the early
postoperative period following traditional lipoplasty
(Figures 3 and 4). Digital photography of patients who
Volume 28 • Number 4 • July/August 2008 • 433
A
C
B
Figure 5. A, Preoperative view of a 21-year-old woman. B, Postoperative view 48 hours after 4250 mL total aspirate was removed by VASERassisted lipoplasty. C, Postoperative view 60 days after VASER-assisted lipoplasty.
A
C
B
Figure 6. A, Preoperative view of a 29-year-old woman. B, Postoperative view 48 hours after 6600 mL total aspirate was removed by VASERassisted lipoplasty. C, Postoperative view 30 days after VASER-assisted lipoplasty.
underwent VAL of their back and posterior flanks
revealed relatively minimal ecchymosis in the early postoperative period (Figures 5 and 6). This substantiates
previous similar clinical findings by Jewell et al.5 and de
Souza Pinto et al.15 None of the patients in this study
sustained any VASER-related complications.
DISCUSSION
When all parameters are kept equal, the amount of
blood in lipoplasty aspirate is location-dependent in a
given patient. Tight, fibrous anatomic areas, such as
the back and posterior flanks, are associated with a
greater amount of blood loss during lipoplasty procedures than “soft areas,” such as the lower abdomen or
medial thighs. VAL was always associated with a cleaner aspirate; however, in the “soft areas” the blood content of the aspirate was only slightly lower when
compared to SAL. It is in the posterior flanks and back
areas where the significant differences between VAL
and SAL become apparent. Our data, based on aspirate
from these anatomic areas, quantitatively confirms previous clinical observations that VAL is associated with
434 • Volume 28 • Number 4 • July/August 2008
significantly less blood loss than SAL. When using
bloody aspirate as the “end point” before removal of
the desired amount of aspirate in posterior trunk
lipoplasty, we were able to remove an average of 3.1
times more aspirate from the back and posterior flanks
by using VAL as compared with SAL before the end
point was reached.
CONCLUSION
We conclude that VAL should be considered for patients
undergoing large-volume lipoplasty procedures or
lipoplasty of tight, fibrous areas such as the back and
posterior flanks where increased blood loss is expected. ◗
DISCLOSURES
The authors have no financial interest in and received no compensation from manufacturers of products mentioned in this article.
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Accepted for publication March 6, 2008.
Reprint requests: Onelio Garcia, Jr, MD, Merrick Pointe Bldg., Suite 102,
3850 Bird Road, Miami, FL 33146. E-mail: [email protected].
Copyright © 2008 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$34.00
doi:10.1016/j.asj.2008.04.002
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