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ERN INT ATI IBUTION TR AL CON ON 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. REFERENCES 1. The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank, Procedural Statistics, 2006. New York: The American Society for Aesthetic Plastic Surgery; 2007. Aesthetic Surgery Journal 2. Rohrich RJ, Beran SJ, Kenkel JM, Adams Jr WP, DiSpaltro F. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg 1998;101:1090–1102. 3. Fodor PB, Watson J. Personal experience with ultrasound-assisted lipoplasty: A pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg 1998;101:1103–1116. 4. Baker Jr JL. A practical guide to ultrasound assisted lipoplasty. Clin Plast Surg 1999;26:363–368. 5. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA. Clinical application of VASER-assisted lipoplasty: A pilot clinical study. Aesthetic Surg J 2002;22:131–146. 6. Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg 1992;16:287–298. 7. Maxwell GP, Gingrass MK. Ultrasound-assisted lipoplasty: A clinical study of 250 consecutive patients. Plast Reconstr Surg 1998;101:189–202. 8. Matarasso A. Ultrasound-assisted lipoplasty: Is this new technology for you? Clin Plast Surg 1999;26:369–375. 9. Scuderi N, Paolini G, Grippaudo FR, Tenna S. Comparative evaluation of traditional, ultrasonic and pneumatic-assisted lipoplasty: Analysis of local and systemic effects, efficacy and costs of these methods. Aesthetic Plast Surg 2000;24:395–400. 10. Grotting JC, Beckenstein MS. The solid probe technique in ultrasoundassisted lipoplasty. Clin Plast Surg 1999;26:245–254. 11. Zukowski M, Ash K. Ultrasound-assisted lipoplasty learning curve. Aesthetic Surg J 1998;18:104–110. 12. Rohrich RJ, Beran SJ, Kenkel JM. Complications. In: Rohrich RJ, Beran SJ, Kenkel JM, eds. Ultrasound-assisted liposuction, 1st ed. St. Louis, MO: Quality Medical Publishing; 1998:347–362. 13. Young VL, Schorr MW. Report from the conference on ultrasoundassisted liposuction safety and effects. Clin Plast Surg 1999;26:481–524. 14. Mladick RA. Discussion: Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg 1998;101:1117–1119. 15. de Souza Pinto EB, Abdala PC, Maciel CM, dos Santos Fde P, de Souza RP. Liposuction and VASER. Clin Plast Surg 2006;33:107–115. 16. The American Society for Aesthetic Plastic Surgery, Cosmetic Surgery National Data Bank, Procedural Statistics, 2005. New York: The American Society for Aesthetic Plastic Surgery; 2006. 17. Illouz YG. Refinements in the lipoplasty technique. Clin Plast Surg 1989;16:217–233. 18. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltration in suction-assisted lipoplasty: A review. Plast Reconstr Surg 1997;99:514–519. 19. Hetter GP. The effect of low-dose epinephrine on the hematocrit drop following lipolysis. Aesthetic Plast Surg 1984;8:19–21. 20. Fodor PB, Watson JP. Wetting solutions in ultrasound-assisted lipoplasty. Clin Plast Surg 1999;26:289–293. 21. Rohrich RJ, Beran SJ, Kenkel JM. Anesthetic considerations. In: Rohrich RJ, Beran SJ, Kenkel JM, eds. Ultrasound-assisted liposuction, 1st ed. St. Louis, MO: Quality Medical Publishing, 1998:69–84. 22. Kloehn R. Liposuction with “sonic sculpture”: Six years’ experience with more than 6000 patients. Aesthetic Surg Q 1996;16:123–128. 23. Zocchi ML. Ultrasonic-assisted lipoplasty. Clin Plast Surg 1996;23:575–598. 24. Scheflan M, Tazi H. Ultrasonically assisted body contouring. Aesthetic Surg J 1996;16:117. 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 Blood Loss in SAL and Third-Generation Internal UAL Volume 28 • Number 4 • July/August 2008 • 435