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®
COSMETIC SURGERY TIMES
4
Shaping innovation
Cosmetic surgeons discuss what they see as the most promising body-contouring
advancements hitting the market today — and potentially tomorrow
Q: “Body contouring” is a broad category.
In the context of your practice and patient
population, what technique or technology has
enhanced the procedures you perform?
Julius W. Few, M.D., F.A.C.S.
Chicago
“Body contouring continues
to be a major area of interest,
with liposuction continuing to
be the most popular surgical
application, according to data
from the American Society for
Aesthetic Plastic Surgery. While
Dr. Few
there is exciting potential on the
horizon for nonsurgical, energybased therapies that make unwanted fat go away,
there continues to be a place for liposuction.
I have found, in my practice, a unique area
somewhere between traditional liposuction and
the newer noninvasive approaches.
“Laser-assisted liposuction is an approach that
has gained wide popularity in my practice. I
use the technology very conservatively as an
in-office utility. In my AAAASF-accredited
operating room, I perform small to moderate
laser liposuction cases under local anesthesia
with an oral sedative. The typical patient
is close to ideal body weight with areas of
unwanted fat. These are patients who would
not ever consider traditional liposuction,
several of whom include physicians.
“Using moderate doses of energy and taking
care not to overheat the tissue, the process
is predictable with a rapid delivery of results
and minimal recovery. I just saw a patient
yesterday who had two rounds of noninvasive
fat reduction at another office, without
benefit (The patient is the best friend of my
laser liposuction patient and she was the
designated driver for my patient after her
surgery). She was absolutely shocked at the
recovery and lack of real discomfort after laser
surgery. In particular, she was astounded by
the immediate nature of her friend’s result and
ability to return to office work the next day,
after abdominal and flank laser liposuction
(500 cc yield).
“
I have incorporated
laser liposuction into my
practice for two years now
and find that it has not only
invigorated my practice,
with increases of
approximately 15 percent
each year in liposuction
cases, but it has improved
the overall results.
Joel Schlessinger, M.D.
Omaha, Neb.
”
“Here are the reasons I feel laser-assisted
liposuction, or Slim Liposuction (Palomar
Medical), has clinical benefit. The 1.5 mm
fiberoptic probe allows for a very small point
of access to the patient. Much like with
ultrasonic liposuction, I treat to resistance
and avoidance of overheating the skin, not
an arbitrary temperature. The liquification
process then allows for small cannula
placement to aspirate the emulsified fat. The
smaller cannula and small point of access, I
believe, account for consistent reports of less
pain and swelling after the procedure. I have
found that patients really only need support
garments for a week or so in many cases.
“I am excited to see the next wave of
nonsurgical technology and related
refinement. I believe this is an area of growth
in aesthetic medicine and opens the door to
patients previously unavailable. My prediction:
Stay tuned for high-frequency ultrasound
applications and further refinement of
cryolipolysis. Ultimately, patient safety is the
most important issue, and proper training and
experience is vital with all technologies.”
Joel Schlessinger, M.D.
Omaha, Neb.
“While tumescent liposuction
has been popularized since
the early 1990s, there haven’t
been many changes in the
original procedure since Dr.
Jeff Klein presented the
Dr. Schlessinger concept. Over time, several
fads have come and gone,
including ultrasonic-assisted
liposuction, external ultrasonic liposuction
and, most recently, high-frequency ultrasound.
These have been accompanied with laserassisted options to varying degrees.
“While I have investigated these and briefly
incorporated them into my practice, the truth is
that they didn’t make a significant improvement
in my abilities to either harvest fat or accomplish
a better result. The most recent innovation, laser
liposuction (Smartlipo by Cynosure in my case,
although many different lasers are available),
has made a positive impact on my practice and
continues to impress me.
“I have incorporated laser liposuction into
my practice for two years now and find that
it has not only invigorated my practice, with
increases of approximately 15 percent
6
each year in liposuction cases, but
MOTHER’S
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BEFORE
AFTER 8 WEEKS
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Mark Youssef, MD Cosmetic Surgeon and his mother, Magda Youssef.
my
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Now I have hundreds of patients using this eye cream and I feel confident recommending
this eye product to my patients. I simply tell them that it helps “brighten, tighten and
lighten” the eye skin.
Photos courtesy of Dr. Mark Youssef.
Photos of Dr. Youssef’s mother, Magda Youssef.
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Mark Youssef, MD Cosmetic Surgeon
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COSMETIC SURGERY TIMES
6
it has improved the overall results. It is
important to detail the benefits and explain
the potential drawbacks, however.
“The benefits of this procedure include
primarily those to the surgeon and those to
the patient. From a surgeon-centric viewpoint,
laser liposuction tends to ease the entry into
the fat (especially with fibrous areas) and
decreases the wear and tear on the operator/
surgeon’s arm. This is a huge benefit in my
opinion and among my colleagues who have
adopted this technique.
“Additionally, more patients are curious
about this than the previous, older method of
liposuction. As such, this can lead to higher
revenue, as it has in my case. Given the
burgeoning entrance of medspas and less
proficient/trained individuals into the liposuction
field, the ability to offer this technique may
confer a minor, albeit helpful, advantage to a
cosmetic surgery practice. One caveat is that
many new entrants into the cosmetic surgery
field (including medspas run by non-core trained
doctors) offer this technique, as the laser
companies willingly sell it to anyone with an
M.D. after their name, so it may not be a true
advantage in your region/town.
“Advantages to the patient include a
slightly higher yield in fat per session. I
have consistently found approximately 200
cc to 400 cc more fat obtained per laser
liposuction session. This advantage is
particularly welcome in the male breast area
and when doing repeat procedures in areas
where there is scarring or fibrous tissue.
“Disadvantages include the cost of the
laser, which can be well over $100,000
and can include disposable items. From the
standpoint of time efficiency, I find that it
adds approximately 15 to 20 minutes to each
procedure. While this is a negligible amount,
it has to be considered. For this reason, we
charge more when using the laser for our
tumescent liposuction procedures.
“In some cases, these lasers can cause
burns to the skin and undersurface. I have
deliberately kept my 18-watt machine that
has one laser, rather than upgrading to a
more powerful machine for this reason. It is
my thought that safety and the avoidance of
adverse events is paramount in importance,
and I would urge every surgeon considering this
procedure to carefully limit the power they use
initially and only increase energies as needed.
“The other disadvantage is a theoretical one,
based on trends in the future and adoption
rates by classically/core-trained surgeons versus
medspa doctors. It is quite possible that the
technique will suffer if it is predominantly
practiced by medspa doctors and their
equivalents. Time will tell, and I am hoping that
as more core surgeons realize the benefits of
this procedure it will become more mainstream,
allowing for a renaissance of this procedure.”
Efrain Gonzalez, M.D., F.A.C.O.G., F.A.C.S.
Sacramento, Calif.
“More women are seeking assistance to sculpt
their body than ever before with the influence of
celebrities like Kim Kardashian, Jennifer Lopez
and Beyoncé. The trend is that many women
are not only requesting breast augmentation
but also buttock augmentation
(Buttock augmentation has
increased 153 percent in the
past three years!). It is this
procedure that has become the
most sought-after procedure in
my practice, and the one that
has had the biggest influence in
Dr. Gonzalez
my approach to body sculpting.
“The buttocks play an extremely important
role in the overall shape of the female body —
the buttock projection and the curve created
by the waist and hips together are the main
feature of a woman’s contour. To increase a
patient’s buttocks, you’ve got two options:
fat grafting and silicone implants. While fat
grafting relies on extracting from a donor site
on the body, silicone implants can be used
in all patients, including those that have no
fat to transfer to the buttocks. Implants also
offer the advantage of giving you a steady and
consistent result.
“
More women are seeking
assistance to sculpt their
body than ever before
with the influence of
celebrities like Kim
Kardashian, Jennifer Lopez
and Beyoncé. The trend is
that many women are not
only requesting breast
augmentation but also
buttock augmentation.
Efrain Gonzalez, M.D., F.A.C.O.G., F.A.C.S.
Sacramento, Calif.
”
“Fat grafting is performed by first liposuctioning
the area of the body where you want to obtain
fat. This is usually the abdomen, love handles,
lower and upper back or thighs. An artistic
approach to removing fat can also help with
further enhancement of the buttocks area.
When the prepared fat is injected into the
buttocks, it is best to overfill the areas. The
more fat that is added, the better the final
result, since some fat will be reabsorbed. In
my patients, I aim to add at least 600 cc per
cheek, with as much as 800 per cheek.
“The downside to fat grafting? Your patients
may need another procedure, a fact that must
be clearly communicated to them.” Doctors’ Bios:
Julius Few, M.D., F.A.C.S., is a board-certified plastic
surgeon and director of The Few Institute for Aesthetic
Plastic Surgery in Chicago. Dr. Few also serves as a clinical
associate in Plastic Surgery at the University of Chicago, in
addition to being the immediate past president of the Illinois
Society of Plastic Surgeons. Dr. Few is a consultant for
Palomar Medical.
Joel Schlessinger, M.D., is the president emeritus of the
American Society of Cosmetic Dermatology and Aesthetic
Surgery and is the past president of the Nebraska Dermatology Society. Board-certified in dermatology, cosmetic
dermatologic surgery and pediatrics, he started his own
conference, Cosmetic Surgery Forum (held in Las Vegas),
in 2009, which is now entering its third year. Dr. Schlessinger reports no relevant financial interests.
Efrain Gonzalez, M.D., F.A.C.O.G., F.A.C.S., is the founder
and medical director of Advanced Medical Spa in Sacramento, Calif. Dr. Gonzalez is a fellow of the American
Academy of Cosmetic Surgery as well as a fellow of the
American College of Surgery. Dr. Gonzalez reports no
relevant financial interests.
GETTY IMAGES: PHOTOALTO/ALIX MINDE
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COSMETIC SURGERY TIMES
8
Massive weight loss procedures
create unique challenges for
body contouring surgery
Cheryl Guttman
Krader
S ENIOR S TAFF CORRESPONDENT
Quick
read
GETTY IMAGES: PAUL VIANT
New surgical solutions have been
needed to address the complex skin
and soft-tissue deformities present
in patients after massive weight
loss. Members of the plastic surgery
community highlight some ways they
have responded to these challenges.
Dr. Aly
T
he success of bariatric surgery has created
a new population of patients seeking body
contouring, but the deformities they present
with are unlike any that plastic surgeons had
encountered before. The need to solve the technical
challenges represented in these patients and a desire
to help restore patient self-esteem has driven surgical
innovation within the plastic surgery community.
As faculty members at the University of Iowa, the
birthplace of bariatric surgery, Al S. Aly, M.D., and Albert
E. Cram, M.D., had early exposure to massive-weightloss patients needing body-contouring surgery, and they
have become leading experts in the field. Recognizing
that traditional abdominoplasty failed to address the
circumferential lower-truncal-tissue excess present
in massive-weight-loss patients, they introduced belt
lipectomy as a more appropriate and effective alternative.
Using an incision that extends around the entire trunk
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COSMETIC SURGERY TIMES
10
Lipectomy
continued
v
to enable circumferential excision of skin and
fat, the procedure not only improves abdominal
contour, but also eliminates lower back rolls
and provides a buttock lift, says Dr. Aly, clinical
professor of surgery, School of Medicine,
University of California, Irvine.
However, despite a number of publications
in the peer-reviewed literature describing the
technique and its outcomes, belt lipectomy
has yet to be widely adopted by U.S. plastic
surgeons. Hopefully, that situation will be
changed by greater surgeon education and
recent modifications in the technique (see
sidebar, “Belt Lipectomy”), Dr. Aly says.
Belt
lipectomy
Surgical modifications may encourage
adoption for massive-weight-loss patients
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
Complex deformities of the upper body are
also a unique finding following massive weight
loss and have resulted in the development of
upper-body lifting and breast-reconstruction
procedures specific for this patient population.
Significant descent of the lateral inframammary
crease is a major issue seen in both genders
and is the indication for an upper body lift, Dr.
Aly says.
“Whether the patient is a woman who would
benefit from breast augmentation or a man
who needs breast reduction, the breast surgery
must be performed on a flat base, as if building
a pyramid on an even base. Lifting of the
inframammary crease into its correct position is
a necessary first step,” he says.
ADDRESSING THE BREASTS To address
the deflated breast deformity that can occur
after massive weight loss, Peter
Rubin, M.D., and colleagues
at the University of Pittsburgh
have developed a mastopexy
technique involving dermal
suspension and parenchymal
reshaping with transfer of
autologous tissue. Although Dr.
Dr. Rubin
Rubin acknowledges it may still
be too early to consider the procedure mature,
he says it has been performed with very good
results in more than 130 patients representing a
difficult population.
The incisions for the procedure are based on
an extended keyhole-pattern mastopexy. After
removing epithelium from a very broad surface
area of the breast, the underlying dermis is
suspended to the ribs and chest-wall fascia
in order to create an internal “brassiere.”
Tissue from the side of the chest can then be
transferred to the breast area to increase breast
size.
Irvine, Calif. — Belt lipectomy that addresses
circumferential excess tissue is the procedure
of choice for truncal contouring in massiveweight-loss patients. This procedure has not
been widely adopted by plastic surgeons in
the United States, however, and the majority
of massive-weight-loss patients seeking
body contouring to address post-weight-loss
deformities are inappropriately undergoing
abdominoplasty instead.
Recently, innovations in technique have
improved the efficiency of belt lipectomy and
reduced its complication rate. These advances
may encourage more plastic surgeons to learn
the procedure so they can provide optimal body
contouring for massive-weight-loss patients,
says Al S. Aly, M.D.
Dr. Aly is clinical professor of surgery, School
of Medicine, University of California, Irvine, and
he pioneered the belt lipectomy procedure in
collaboration with Albert E. Cram, M.D., when
they were faculty members at the University of
Iowa, Iowa City.
CLOSURE Dr. Aly notes that the closure,
which was the most time-consuming portion of
the operation, was the target for several of the
changes. Originally, the deep layers were closed
using interrupted sutures and the superficial
layers were closed with either interrupted or
running sutures. About three years ago, Dr.
Aly began using barbed sutures to plicate the
abdominal wall and the deep layers; absorbable
subcuticular staples for the superficial layer
closure; absorbable subcuticular running
monofilament suture; 3-0 Monocryl (Ethicon)
to approximate skin edges; and tissue glue
(Dermabond, Ethicon).
“The closure in belt lipectomy takes a very
long time because the incisions are so long.
Each of the modifications in closure technique
speeds up the respective step, and when used
together, there is a significant reduction in total
operative time. A shorter procedure is a safer
one,” Dr. Aly says.
REDUCING SEROMA Other surgical
modifications have aimed to reduce the
rate of seroma, which is the most common
complication of the circumferential procedure.
Instead of elevating the abdominal flaps at
the level of the rectus fascia as originally
performed, a revised technique elevates the
flap at or just below the Scarpa fascia. That
modification by itself reduces the risk of
seroma, but in addition, placement of quilting
sutures to close the dead space between the
flap and abdominal wall seems to provide
further benefit, Dr. Aly says.
Quilting sutures were first popularized by
Ricardo Baroudi, M.D., Sao Paulo, for use in
abdominoplasty, and Harlan and Todd Pollock,
M.D., a father-and-son team of plastic surgeons
in Dallas, introduced their own modification
that they’ve termed progressive tension sutures.
“By any name, these sutures seem to
significantly reduce the risk of seroma.
However, while their use and the modification
in flap elevation technique have been well
adopted by plastic surgeons in South America
and Europe, they are catching on more slowly
in the U.S.,” Dr. Aly says.
Disclosures:
Dr. Aly is a consultant for Ethicon and has a financial interest in
Incisive Surgical, the maker of the subcuticular stapler.
APRIL 2011
11
“With this procedure, the surgeon can precisely
restore an aesthetically pleasing breast shape
without using any artificial or biologic materials
and while simultaneously being able to eliminate
rolls of skin and fat from the side of the breasts.
This versatility and control are important
advantages of the technique,” says Dr. Rubin,
chief of plastic surgery, University of Pittsburgh.
“
As a resident, I was
taught that the scar in an
upper-arm lift had to be in
the bicipital groove, but
there is really no standard
of care for scar
placement in these
procedures. Rather,
this decision should
depend on the
surgeon’s ability and
experience along with the
patient’s desires.
Al S. Aly, M.D.
University of Iowa
”
“There is a low complication rate of about
3 percent to 5 percent, and most of the
complications we’ve seen are minor woundhealing problems in the lower pole of the breast.
Patients should realize this is not a short-scar
operation, but the trade-off for accepting that
limitation is the success of the procedure for
creating a better breast shape,” he says.
Dr. Rubin says the breast-reshaping procedure
can be combined with an upper-body lift in
which the scar can run either across the upper
back in the bra line or on the sides of the chest,
depending on the surgeon’s and the patient’s
preference for scar location and the patient’s
body type. When an upper-body lift is performed
with breast reshaping, the scars from the
two procedures can be merged such that the
incision from the upper-body lift is brought onto
the front of the chest and hidden in the folds
beneath the breasts, Dr. Rubin says.
UPPER AND LOWER EXTREMITIES
Drs. Cram and Aly also have been innovators
in addressing the massive skin and soft-tissue
redundancy of the upper arms that can be
present in massive-weight-loss patients. So as
to eliminate the full extent of tissue excess,
their technique uses an incision that begins in
the posterior aspect of the arm and extends
across the axilla and onto the side of the chest.
In contrast to approaches using an incision
placed in the bicipital groove and terminating
at the axilla, their technique provides a superior
cosmetic outcome while also reducing the risk of
postoperative lymphedema and avoiding injury
to the medial cutaneous antebrachial nerve, Dr.
Aly says.
“As a resident, I was taught
that the scar in an upper-arm
lift had to be in the bicipital
groove, but there is really
no standard of care for scar
placement in these procedures.
Rather, this decision should
depend on the surgeon’s ability
and experience along with the
patient’s desires,” he says.
“Nevertheless, posterior scar
placement is probably the
most widely used worldwide for
addressing the severe upperarm deformities present after
massive weight loss because of
the reasons I’ve mentioned.”
Hanging folds of skin in the
inner thigh are also problematic
for massive-weight-loss
patients, but addressing these
lower-extremity deformities
remains a challenge, says Dr.
Cram, in private practice in
Iowa City, Iowa.
Dr. Cram’s current approach
for thigh contouring begins
with heavy liposuction of the
anterior and lateral aspects
of the upper thigh as needed,
performed as part of the
belt lipectomy. Resection of
excess thigh tissue is carried
out as a separate procedure
with very aggressive medial
thigh liposuction followed by a
vertical ellipse excision of skin.
“When the aggressive medial
liposuction is finished, the
regional lymphatics are
seen to remain intact. This
explains why we have not seen
problems with the development
of lower-extremity lymphedema
as has occurred with other
thighplasty techniques,” Dr.
Cram says.
“The vertical lift does result
in a long scar, but in contrast to thighplasty
using a horizontal incision running parallel to
the upper thigh-pelvic junction, the vertical
approach avoids tension on the vulvar tissue
that can lead to labial distortion and patient
discomfort,” he adds.
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COSMETiC SUrGErY TiMES
12
Regional liposuction,
fat transfer optimal
for buttock enhancement
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
A
s demand for buttock
augmentation
continues to increase,
surgeons interested
in offering this cosmetic procedure
should recognize that aggressive
regional liposuction combined with
fat transfer is the safest and most
reliable method for achieving good
results, according to Marco Pelosi III,
M.D.
Quick
read
GETTY IMAGES: PANDO HALL
Dr. pelosi
Fat transfer enables safe and
controlled buttock reshaping.
Marco pelosi iii, M.D., describes
his use of regional liposuction to
enhance the contour and his fattransfer technique that optimizes
graft survival and outcome based
on volume of available fat.
“Beware that certain injectable
materials used in other countries for
buttock reshaping are illegal in the
U.S. and have been associated with
complications, including necrosis
and granuloma formation,” says Dr.
Pelosi, chairman of obstetrics and
gynecology, United States Section of
the International College of Surgeons,
and associate director, Pelosi Medical
April 2011
13
Center, Bayonne, N.J. “Fat or preformed
silicone implants are the only safe methods
for buttock augmentation, but considering
ease and ability to control the final outcome,
fat is clearly the superior product.”
Laying the foundation Aggressive
liposuction to remove tissue that is competing
for attention in the buttock region followed
by careful planning to determine the area of
augmentation are the first steps to achieving
a good result. Liposuction concentrating on
the mid- and lower flanks and the midline
immediately above the buttock crease
narrows the waist and improves the flow of
the sacral curve into the buttock. By itself,
“
Even aggressive liposuction
with large cannulas can
sometimes adversely
affect the quality of the
fat, and so we take the
fat with a nonthermal,
very atraumatic technique
using cannulas no larger
than 3 cm in diameter.
Marco Pelosi III, M.D.
Bayonne, N.J.
”
the liposuction enhances the appearance of
buttock size and contour, Dr. Pelosi says.
“Removing a triangular-shaped fat deposit
that is often present above the buttock crease
sculpts a ‘V’ shape emanating out of the
buttock apex and produces a cleavage type of
effect with a sharply defined curvature from
the top of the buttock outward,” he says.
“This goes a long way toward creating a visual
impression of upper buttock roundness that
is a good starting point for achieving a nicely
flowing contour with the augmentation.”
To define the perimeter of the area for the fat
injections, Dr. Pelosi identifies the edges of
the gluteus by palpation while the patient is
standing and marks a preliminary template
that he then views from across the room.
“Patients should be standing for the
assessments, because that is the position in
which they will look at themselves to decide
their satisfaction, and to fully appreciate
the expected outcome, the surgeon needs to
make the initial assessment by taking a long
versus close-up view,” Dr. Pelosi says.
A female patient (left) with localized adiposity of the flank and sacral regions, which masks the curvature of the upper
buttocks. The same patient (right) three months after aggressive liposuction of the flank and sacral fat and autologous
transfer of 500 ml of fat to each buttock. The upper buttock curvature is clearly defined and projection of the entire buttock
is enhanced. (Photos credit: Marco Pelosi III, M.D.)
He says he often takes digital photographs
of the marked patient and views them on the
computer to refine his plan about shape.
technicaL eLements In order to
optimize viability of the harvested adipose
tissue, the fat removal is performed using
standard liposuction without any additional
technology, such as ultrasound or laser
assisted-lipolysis.
“Even aggressive liposuction with large
cannulas can sometimes adversely affect
the quality of the fat, and so we take the fat
with a nonthermal, very atraumatic technique
using cannulas no larger than 3 cm in
diameter,” Dr. Pelosi says.
Similarly, the method for preparing the fat for
transfer is based on a goal of maximizing its
quality. Usually, the fat is allowed to separate
by gravity alone, but if the lipoaspirate
appears very bloody, centrifugation is used
to remove the blood that can cause irritation
and be detrimental to healing.
The fat is injected from the center outward
with multiple low-volume passes, beginning at
about the inner two-thirds of the oval drawn
to outline the augmentation. Beginning more
centrally causes the tissue to tent up and
makes injection into the perimeter easier
and more accurate. Once the initial bolus
is delivered, the fat is placed in a circular
pattern out toward the periphery.
The same patient illustrated above, marked preoperatively.
Areas targeted for aggressive liposuction are marked in
blue. The initial central zone for fat injection is marked in
red, and the majority of the volume will be deposited
above the “equator” line.
The targeted site of fat delivery depends on
the amount of volume available for transfer.
In low-volume cases, the fat is placed nearer
to the surface, because fat placed deeper will
be more compressed, decreasing the volume
achieved. In addition, the augmentation
concentrates on the upper half of the buttock,
where the transferred fat will create a ledge
that enhances curvature show through the
clothing. When more fat is available, the
fat is first injected to create a deeper
14
foundation upon which layers are
COSMETiC SUrGErY TiMES
14
Buttocks
continued
built. This approach results in a softer
surface texture, Dr. Pelosi says.
Any fine-tuning is done by viewing the patient
in a standing position, and as a finishing
touch, platelet-rich plasma is injected into the
area of fat transfer. The latter injections are
delivered using a smaller-gauge needle and
slow passes. Dr. Pelosi says he believes this
technique allows more even distribution of the
mediators than if they were simply added to
the entire aliquot of fat prior to transfer.
“
Some fat-transfer
techniques go deeper into
the gluteus muscle to take
advantage of the blood
supply, but we found that
is usually not necessary
and that we can achieve a
similar outcome with less
patient morbidity by
placing the fat onto the
surface of the muscle
fascia and layering it from
there out to the skin.
Marco Pelosi III, M.D.
Bayonne, N.J.
”
PostoP consideRations
Postoperatively, patients experience only
minimal discomfort.
GETTY IMAGES: ALTRENDO IMAGES
“Some fat-transfer techniques go deeper into
the gluteus muscle to take advantage of the
blood supply, but we found that is usually
not necessary and that we can achieve a
similar outcome with less patient morbidity by
placing the fat onto the surface of the muscle
fascia and layering it from there out to the
skin,” Dr. Pelosi says.
During the first postoperative week, patients
are instructed to wear a compressive pad
at the top of the buttock crease that will
promote adherence between the skin and
muscle tissue and maintain the desired
cleavage. The pad can be fashioned from any
material, but Dr. Pelosi folds a laparotomy
pad into a triangle and shows patients how to
tuck it into their compression garment.
Patients are told to lean forward when they
are sitting down, as if riding on a motorcycle,
and may use a small rolled towel between
“
After having this
procedure, some patients
are motivated to drop a few
extra pounds, but the
transplanted fat is
desperately seeking a blood
supply and we don’t want
the patients to starve
the transferred fat by
dieting.
”
Marco Pelosi III, M.D.
Bayonne, N.J.
the buttocks and posterior thighs to assist
them in maintaining this position. Other
instructions include avoiding cigarette
smoking, which will compromise fat viability,
and refraining from dieting for three months.
“After having this procedure, some patients
are motivated to drop a few extra pounds, but
the transplanted fat is desperately seeking a
blood supply, and we don’t want the patient
to starve the transferred fat by dieting,” Dr.
Pelosi says.
“We also like to wait three months before
doing any additional augmentation in order to
allow for vascularization that will be needed
to support the survival of newly transferred
fat,” he adds. Disclosures:
Dr. Pelosi reports no relevant financial interests.
APRIL 2011
15
Patients seeking relatively modest fat reduction
for quicker, less painful procedures fuel demand
for noninvasive lipolysis platforms
Cheryl Guttman Krader
Quick
read
S ENIOR S TAFF CORRESPONDENT
GETTY IMAGES: PHOTOALTO/MICHELE CONSTANTINI
High consumer interest underlies
growth in research and technology
for noninvasive lipolysis
technologies. Several options are
available and others are under
investigation, but questions about
efficacy, safety and durability remain
to be answered, one physician says.
Dr. Butterwick
A
s industry responds to
consumer interest in
noninvasive cosmetic
procedures, several
modalities for noninvasive fat removal
have been introduced — and more
are on the horizon.
However, data from well-designed,
controlled studies are needed to
better determine how well these
methods work and the longevity
of their results, says Kimberly J.
Butterwick, M.D., who spoke at the
69th annual meeting of the American
Academy of Dermatology in February.
“Liposuction may be one of the
most popular invasive cosmetic
procedures, but it only represents
the tip of the iceberg compared to
the market opportunity for noninvasive body contouring,” says Dr.
Butterwick, a dermatologist and cosmetic surgeon in private practice
in San Diego.
“Available evidence suggests the marketed and investigational
techniques usually produce modest reductions in body circumference
at best, and so they are clearly not a replacement for liposuction,
and while safety seems acceptable with most methods when used
appropriately, there are potential concerns,” she says. “With more
information on outcomes of noninvasive lipolysis needed and research
and technology rapidly evolving, physicians interested in offering these
procedures might be cautious about jumping on the bandwagon too
soon.”
Consumer interest is high, however, and devices that are easy and
safe, and will help patients lose even 1 inch, will be popular.
Currently, approved methods for noninvasive lipolysis include use
of a low-level, 635 nm diode laser (Zerona, Erchonia), cryolipolysis
(CoolSculpting, Zeltiq) and radiofrequency devices.
16
Mesotherapy and focused external ultrasound platforms are
COSMETIC SURGERY TIMES
16
Noninvasive
continued
awaiting approval from the Food and Drug
Administration (FDA).
MARKET CHOICES A published,
uncontrolled study evaluating the 635 nm
diode laser (Jackson RF, Dedo DD, Roche GC,
et al. Lasers Surg Med. 2009;41(10):799809) reported that patients achieved an
average reduction of slightly more than 5
inches circumference over the waist, hips and
thighs after two weeks. The device has been
met with skepticism, however.
“
Before and after photos
indicate that cryolipolysis
can result in visible
reduction in fat bulges,
but the other side of
the coin is that some
patients — perhaps up
to 30 percent, based on
anecdotal reports — are
disappointed with
the outcome.
Kimberly Butterwick, M.D.
San Diego
”
“Because the adipocyte cells are not
destroyed, the results are probably
temporary,” Dr. Butterwick says.
Radiofrequency devices for noninvasive
lipolysis feature monopolar energy
modes that sufficiently penetrate to
reach fat. Published data from studies
using a combination bipolar and unipolar
radiofrequency device (Accent, Alma Lasers)
show contraction of approximately 20 percent
fat volume (Rosado RH, del Pino EM, Azuela
A, et al. J Drugs Dermatol. 2006;5(8):714722). Dr. Butterwick says she has found
that off-label treatment with the unipolar
ThermaCool (Solta Medical) unit can reduce
a thin layer of fat, but the procedure can be
very painful, especially when used on the
upper arms.
Equipped with an adjustable cooling tip,
another proprietary monopolar radiofrequency
platform (Exilis, BTL Industries) reaches
multiple levels of fat, but still only achieves
up to 2.5 cm penetration into the adipose
layer, Dr. Butterwick says. The treatment
uses no disposables, and in clinical use, the
procedure appears to be more comfortable
for patients compared to other monopolar
radiofrequency devices.
“However, a course of treatment involves
four shorter weekly sessions instead of one
longer procedure, and burns are still a risk,
as with any radiofrequency treatment,” Dr.
Butterwick says.
Another commercially available platform
for noninvasive body contouring is based
on cryolipolysis (CoolSculpting, Zeltiq)
that selectively cools fat cells without
causing injury to other tissue. Histological
evidence from a study conducted in a
porcine model shows that the cooling
induces apoptosis and an inflammatory
reaction resulting in clearance of the dead
fat cells by phagocytosis (Zelickson B,
Egbert BM, Preciado J, et al. Dermatol Surg.
2009;35(10):1462-1470). An unpublished
LipoSonix
update
John Jesitus
S ENIOR S TAFF CORRESPONDENT
Approval by the Food and Drug Administration (FDA)
of the LipoSonix device (Medicis) sits on hold. In
July 2010, the FDA told the manufacturer that its
original 510(k) application included insufficient data
to support a finding of substantial equivalence to an
existing device.
Kara Stancell, Medicis vice president, investor and
public relations and corporate communications,
tells Cosmetic Surgery Times that because the
LipoSonix system is not cleared for sale in the
United States, it is inappropriate for the company
to comment about its status. However, published
accounts say, the additional data the FDA
requested did not pertain to safety issues.
The LipoSonix system uses focused ultrasound to
treat persistent fat pockets that do not respond
well to diet or exercise, according to Medicis. Joel
Schlessinger, M.D., says that in European trials,
the device has been shown to cause approximately
1 inch of circumferential decrease in the anterior
abdomen. He is a board-certified dermatologist
and cosmetic surgeon based in Omaha, Neb. “In
the United States, we await publication of the
manufacturer’s final data and study results,” he
says.
Disclosures:
Dr. Schlessinger is an investigator for Kythera and Medicis
and founder of the Cosmetic Surgery Forum, at which the
LipoSonix material was presented.
A patient with “love handles” before (left) and one month after one cryolipolysis treatment with Zeltiq’s CoolSculpting system. There was no reported change in the patient’s
weight between the taking of the before and after images. (Photo credit: William F. Groff, M.D.)
APRIL 2011
17
The device features large and small clamp-like
applicators that hold the patient’s tissue with a
vacuum. The procedure takes about an hour, but
an operator need not be present. Post-treatment
sequelae include redness and sensitivity
that may last for several hours and bruising,
soreness, cramping and tenderness that may
be present for a few days. There are some rare
reports (less than 1 percent) of moderate to
severe paresthesia-related pain persisting for
several weeks, Dr. Butterwick says.
“Before and after photos indicate that
cryolipolysis can result in visible reduction
in fat bulges, but the other side of the coin
is that some patients — perhaps up to 30
Noninvasive ultrasonic
lipolysis may become
available in 2011, as two
investigational devices
have completed clinical
trials and are undergoing
FDA review. Both platforms
use focused, pulsed
ultrasound, but they work via
different mechanisms.
percent, based on anecdotal reports — are
disappointed with the outcome,” she says.
Dr. Butterwick says the results achieved
may depend on how well the targeted area
is drawn into the applicator, which may be
limited at certain anatomic sites or if the
fat deposit is too small. In addition, longer
follow-up is needed to determine the duration
of the result achieved and whether there are
contour irregularities between the treated
and untreated sites.
ON THE HORIZON Noninvasive ultrasonic
lipolysis may become available in 2011, as two
investigational devices have completed clinical
trials and are undergoing FDA review. Both
platforms use focused, pulsed ultrasound, but
they work via different mechanisms.
One device produces a cavitation effect that
disrupts fat cells (Contour 1, UltraShape),
while the other (LipoSonix, Medicis)
destroys fat by a thermal effect (see sidebar,
“LipoSonix update”). Both systems require
an active operator, and the procedure can
take up to 90 minutes when treating a larger
anatomic area.
Clinical studies conducted outside the
United States using the UltraShape platform
show an average circumferential reduction
ranging from 2 cm to 3 cm after a single
treatment and greater reductions after
multiple treatment sessions with high patient
satisfaction rates.
Mesotherapy with a formulation containing
salmeterol xinafoate and fluticasone
propionate (LIPO-102, Lithera) is also
currently under investigation in FDA trials.
This approach, which involves injection of the
lipolytic agent into fat using a small-caliber
needle (30 gauge), has the advantage of
being relatively easy to perform, and limited
evidence suggests that it holds promise for
reducing a layer of fat. Multiple sessions are
needed, however, and safety remains to be
established, Dr. Butterwick says.
“Currently, mesotherapy using various
formulations is being offered in medical and
non-medical settings, but there is no control
over the contents of the solutions being injected,
and there are published reports of significant
complications following mesotherapy, such as
atypical mycobacterium infections. Therefore,
it would seem prudent for patients to avoid this
procedure until and if it becomes cleared by the
FDA,” she says.
“Overall, the outlook for noninvasive lipolysis
has never been brighter,” Dr. Butterwick
says. “We have several safe methods of
reducing some degree of fat and more to
come. Although they won’t take the place of
tumescent liposuction, these procedures can
be repeated to achieve a greater effect, and
they can provide a noticeable result to satisfy
patients willing to settle for less improvement
with a noninvasive treatment.”
Disclosures:
Dr. Butterwick reports no financial interest in the material she
presented at the annual AAD meeting.
GETTY IMAGES: WALKER AND WALKER
clinical study by Geronemus et al using
ultrasound imaging before and after one
session in 10 patients showed the process
resulted in about a 25 percent reduction in
fat layer thickness after four months.
COSMETIC SURGERY TIMES
18
New-generation technology offers a step forward in cellulite
treatment, but room for improvement remains
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
A
new generation of technology
for noninvasive reduction of
the appearance of cellulite is
proving to be more effective
than earlier options. However, there
remains room for further advances,
considering treatment with these
modalities involves multiple sessions
that are associated with local adverse
reactions and results that are still
variable, according to Neil Sadick, M.D.
Quick
read
GETTY IMAGES: RYAN MCVAY
Options for cellulite reduction
continue to proliferate, and some
newer platforms for noninvasive
treatment are offering better results
than have been achieved in the past.
Dr. Sadick
“Research we and others have
conducted to characterize the
histological features of cellulite and
understand its physiology suggest
a protocol using injectable lipolytic
agents that selectively target cellulite
adipose tissue combined with light- or
radiofrequency-based technology may
provide the ultimate answer,” says Dr. Sadick,
clinical professor of dermatology, Weill Medical
College of Cornell University, New York.
Speaking at the 27th annual meeting of the
American Academy of Cosmetic Surgery in
January, Dr. Sadick provided an overview of
recent advances in noninvasive platforms for the
treatment of cellulite.
VELASHAPE II Introduced in 2010, Velashape
II (Syneron) represents the third generation of a
system that combines bipolar radiofrequency and
infrared light energy with vacuum and mechanical
massage to reduce the appearance of cellulite.
It is also approved for circumferential reduction.
Relative to its predecessor, the VelaShape II
features a 20 percent increase in radiofrequency
power to 75 W that results in a faster temperature
rise and reduced treatment time.
APRIL 2011
19
Published studies investigating the earlier
version of this technology demonstrated its
efficacy for reducing subcutaneous fat deposits
in the abdomen and flanks (Brightman L,
Weiss E, Chapas AM, et al. Lasers Surg Med.
2009;41(10):791-798). Another study showed
improvement in cellulite appearance in the
buttocks with benefit noted as early as after
the first of multiple sessions (Romero C,
Caballero N, Herrero M, et al. J Cosmet Laser
Ther. 2008;10(4):193-201).
“
Research we and
others have conducted to
characterize the histological
features of cellulite and
understand its physiology
suggest a protocol using
injectable lipolytic agents
that selectively target
cellulite adipose tissue
combined with light- or
radiofrequency-based
technology may provide the
ultimate answer.
Neil Sadick, M.D.
New York
”
SMOOTHSHAPES XV Also in 2010,
Eleme Medical introduced a second generation
of its technology for cellulite reduction
(Smoothshapes XV) that uses dual laser
(915 nm) and light (650 nm) energy with
massage and suction. Compared with the
previous model, this platform has been
upgraded with a 50 percent increase in power
along with user enhancements that include
audible and visual treatment guidance and
customized treatment settings, Dr. Sadick says.
In a study of 20 women with mild to moderate
cellulite of the lateral thighs, 94 percent of
patients were satisfied with their outcome after
a series of eight treatments, and there were no
adverse events (Kulick MI. Plast Reconstr Surg.
2010;125(6):1788-1796), Dr. Sadick says.
ACCENT XL In 2009, with the introduction
of a new handpiece (UniForm), Alma Lasers
received clearance from the Food and Drug
Administration to use its Accent XL unipolar
radiofrequency device for temporary reduction
in the appearance of cellulite. The handpiece
features the UniLarge radiofrequency tip in
the center and surrounds it with a 50 mm
massager ring that rotates 150 turns per
minute to increase microcirculation and fluid
drainage.
A study investigating radiofrequency treatment
of cellulite on the buttocks and thighs using
the Accent system without the dual-component
handpiece showed that volumetric contraction was
achieved in about two-thirds of patients based
on ultrasound imaging (Rosado RH, del Pino ME,
Azuela A, et al. J Drugs Dermatol. 2006;5(8):714722). Measurements made of the distance
between the stratum corneum and Camper’s
fascia and from the stratum corneum to the
muscle showed 68 percent of patients achieved a
volume contraction of about 20 percent.
REACTION SYSTEM Recognizing that
abnormal skin changes associated with cellulite
involve multiple depths, the Reaction bipolar
radiofrequency system (Viora) combines
three RF frequencies (0.8 MHz, 1.7 MHz and
2.4 MHz) in proprietary technology (CORE,
Channeled Optimum RF Energy) to target the
mid dermis, deep dermis and the subcutaneous
layer. This technology became available in
2009, and Dr. Sadick reports he is involved in
a study evaluating the system in 30 patients
who are undergoing three to six sessions at
four- to five-week intervals.
CELLUPULSE Extracorporeal pulse
activation therapy (Cellupulse, Storz Medical)
is noninvasive technology for cellulite reduction
that targets the subcutaneous tissue with
oscillating acoustic pulses. Performed with
application of a coupling gel onto the skin, the
cavitation-like effect produced by the acoustic
waves decreases fibrosis of subcutaneous
connective tissue, enhances blood circulation
and increases collagen production.
In a randomized study using the untreated
contralateral side as a control, Adatto et al.
reported statistically significant benefit for
improving depressions, elevations, roughness
and elasticity (Adatto M, Adatto-Neilson
R, Servant JJ, et al. J Cosmet Laser Ther.
2010;12(4):176-182). Other investigators
reported improvements in skin elasticity after
three and six months of 95 percent and 105
percent, respectively, along with increased
compactness of the skin structure on ultrasound
imaging following extracorporeal pulse activation
therapy (Christ C, Brenke R, Sattler G, et al.
Aesthet Surg J. 2008;28(5):538-544).
“We evaluated this system in 30 patients who were
treated twice a week for four weeks for cellulite
on the thighs, gluteal region and upper arms. The
initial results are encouraging,” Dr. Sadick says.
Disclosures:
Dr. Sadick has received research support from Osyris and Storz Medical.
He is on the advisory board for Storz and on the speakers bureau for
Eleme Medical and Medicis.
CosmetiC surgery times
20
Advances in RF and ultrasound technologies for facial
and body contouring gaining momentum, experts say
John Jesitus
S ENIOR S TAFF CORRESPONDENT
T
hanks to ongoing refinements with radiofrequency (RF) and ultrasound-based
contouring modalities, these treatments are becoming more versatile and patientfriendly, according to experts at the Cosmetic Surgery Forum, which took place in
Las Vegas in December 2010.
GETTY IMAGES: OLENA CHERNENKO
Quick
read
radiofrequency and ultrasoundbased options for face and body
contouring are continuing to
expand, offering versatility and
user-friendliness to a variety
of patient populations.
In the ultrasound category, the Ulthera device, delivering a treatment called Ultherapy, is
the first and only device cleared by the Food and Drug Administration for noninvasive brow
lifting, says Curt Samlaska, M.D., assistant professor of medicine (dermatology), University
of Nevada School of Medicine. It uses focused ultrasound waves working at a frequency
between 4 mHz to 7 mHz to deposit very precise thermal coagulation points at depths
measuring 3 mm to 4.5 mm below the skin’s surface (White WM, Makin IRS, Barthe PG, et
al. Lasers Surg Med. 2008;40(2):67-75. Laubach HJ, Makin IR, Barthe PG, et al. Dermatol
Surg. 2008;34(5):727-734).
“Ninety-five percent of the energy is focused within a very small area. Only 2.5 percent
of the energy is transmitted above the treatment zone, and 2.5 percent is transmitted
April 2011
21
below,” Dr. Samlaska says. “The unfocused
sound-wave energy is so minimal that there’s
no risk to the epidermis or deeper structures.”
As a result, he says, the device is colorblind.
“You can treat the darkest skin without worrying
about postinfiammatory hyperpigmentation.”
The Ulthera device is also unique in that
ultrasound waves not only provide treatment energy
that contracts and lifts tissue; ultrasound imaging
also allows physicians to visualize tissue as they are
treating in real time, Dr. Samlaska says.
“No other device allows you to directly visualize
your treated areas,” he says, adding that
the device’s precision is also unparalleled.
“Radiofrequency heating is more diffuse, so it
impacts a larger area and is less well-controlled.
And RF treats only the dermal layer. Ulthera is
the only device that can target deeper regions
such as the superflcial aponeurotic layer, which
is what plastic surgeons tighten in a traditional
facelift. Now, for the flrst time, we can treat
that layer without cutting into the tissues and
undermining beneath it.”
With some RF devices, Dr. Samlaska says,
aesthetic physicians may worry that heating
tissues will destroy fat, resulting in an unintended
loss of facial volume. “That’s what’s great about
Ultherapy — with precisely placed microfocused
ultrasound combined with the ability to visualize
the superflcial aponeurotic layer, we can target it
with very precise pinpoint energy without affecting
intervening tissue. So we don’t have to worry about
fat necrosis with Ultherapy,” he says.
Dr. Samlaska says a
full-facial Ultherapy
treatment including the
forehead, cheeks and upper
and lower neck takes him
one to one-and-a-half
hours. His personal protocol
is to use facial nerve blocks.
TreaTmenT parameTers Regarding
I had the procedure done without any pain
medications and I tolerated it just flne. Patients
will feel concentrated heat as the energy is
being deposited, but the sensation is gone
immediately after each individual application.
The highest level of discomfort occurs when
you treat around bony prominences, such as the
jawline and the orbital and temple areas.”
To ensure the most comfortable patient
experience, “I apply anesthesia over the mental
nerves in the mandible, the infraorbital nerve
on the cheeks and the supratrochlear and
supraorbital nerve above the eyebrows,” Dr.
Samlaska says. “I then run a layer of anesthesia
(2 percent lidocaine with epinephrine) along the
entire jawline and chin. I then apply a layer of
anesthesia above the eyebrows and track it along
the lateral and inferior orbital rims. With that, the
patient is completely numb, and we can do very
aggressive treatments without discomfort. It takes
me about 10 minutes to do the anesthesia.”
During the procedure, “We treat to tone,
palpating the skin until we achieve the desired
tone,” Dr. Samlaska says. “So we end up
putting down more lines” of ultrasound pulses
than the device’s manufacturer typically
recommends when treating patients with higher
degrees of skin laxity.
When triggered by the physician, the device’s
transducer delivers a line consisting of
approximately 20 tiny thermal coagulation
points of sound energy spaced 1.0 mm apart
for the 3 mm depth transducer (which treats
the dermis) and 1.5 mm apart for the 4.5 mm
depth transducer (which treats the superflcial
aponeurotic layer).
“It is important to note that this is dual-plane
treatment of the dermis and the superflcial
aponeurotic layer. To treat the forehead, face
and upper portion of the neck, the company’s
recommended guidelines call for approximately
400 lines,” he says.
After treatment, “Patients can see results
immediately. No other device can do that. Then
delayed secondary changes, including remodeling
and thickening of connective tissue, occur,” a
process that can take four to six months, he says.
“Because Ultherapy induces connective tissue
remodeling, I believe the treatment effects last
about two years.” However, Dr. Samlaska says
patients can undergo yearly treatments to perhaps
achieve a cumulative effect.
treatment times, Dr. Samlaska says a full-facial
Ultherapy treatment including the forehead,
cheeks and upper and lower neck takes him one
to one-and-a-half hours. His personal protocol
is to use facial nerve blocks. Many other Ulthera
users utilize various comfort-management
methods, from air coolers to pharmacologics to
nothing, he says.
CompliCaTions Dr. Samlaska says
“In my practice, we have tried various oral
sedatives but have found the blocks to be best.
that Ultherapy’s potential complications are
minimal. They can include transient redness.
“Sometimes, there might be a little swelling
around the orbit that can last a couple hours,”
he says, but the treatment requires virtually
no downtime, so that a patient could attend a
social function a few hours later.
“The main potential complication involves nerves,”
Dr. Samlaska says. Because Ulthera can target
deeper tissues, “If you happen to go over an area
that has a major nerve — such as the temporal
branch of the trigeminal nerve — it’s possible you
could hit that nerve and cause nerve injury.”
Dr. Samlaska says he believes such nerve injuries
will resolve themselves, because the energy
delivered is focused to a pinpoint. This has not
yet been documented, however. In more than
70 cases performed in his offlce, he says, no
signiflcant complications have occurred. According
to Michael Floegel, director, global marketing,
Ulthera, physicians worldwide have performed
more than 20,000 treatments with the device,
with no reports of permanent nerve damage.
At press time, Dr. Samlaska was working
with a team of physicians exploring ways to
increase the number of treatment lines per
patient to provide more aggressive treatments
for patients with excessive laxity.
With the Thermage device,
says Heidi Waldorf, M.D.,
associate clinical
professor of dermatology,
Mount Sinai Medical Center,
New York, “We are
trying to tighten up the
skin.” Therefore, she says
she flnds diffuse RF
heat helpful.
“Speciflcally, these physicians are advising about
the potential of adjusting treatment guidelines
to deliver more lines to those patients with
signiflcant laxity, and fewer lines to those patients
with mild or moderate laxity,” Mr. Floegel says.
“The manufacturer can only recommend a certain
number of lines based on the studies that have
been done so far,” Dr. Samlaska says. “But most
physicians, when they start using equipment,
develop their own feel for it.”
Clinical and product development efforts are
looking to further develop the platform with new
procedure indications and transducers, Mr.
22
Floegel says. “Our vision is to develop an
CosmetiC surgery times
22
Waves
continued
array of additional transducers that enable the
precise deposition of energy anywhere from one to
10 mm below the skin’s surface noninvasively.”
Presently, Dr. Samlaska uses the Ultherapy
device for treating the head and neck. For
body contouring, “We are currently using the
Thermage (Solta Medical) device,” he says.
Thermage for faCe, body With
the Thermage device, says Heidi Waldorf, M.D.,
associate clinical professor of dermatology, Mount
Sinai Medical Center, New York, “We are trying
to tighten up the skin.” Therefore, she says she
flnds diffuse RF heat helpful. “I go over the entire
surface I want to treat, then back over the vectors.”
With this device, she says, “We know it’s
important not to push heating to the point
of severe pain. On a scale of zero to four,
we’re going for about a two without any pain
medications or anesthesia, which means the
patient feels the heat, but it’s very tolerable. If
the patient feels signiflcant pain or starts getting
quite erythematous, we move away from that area
and return later. I do that to reduce the risk of
burning or the delayed atrophy that was reported
in the early years of the technology. The other
way to avoid overly aggressive treatment is to
make sure the patient is safely grounded and to
use a generous amount of the coupling fluid.”
Thanks to the Thermage
device’s recent improvements,
says Dr. Waldorf, “It
flnally delivers what it
promised — a pain-free
treatment with no downtime
that tightens skin.”
Additionally, Dr. Waldorf says the Thermage
device works in one treatment rather than several.
“The soonest I generally repeat the treatment
is at one year, for patients who want to build on
previous results,” she says. Since she started
using the device about 10 years ago, Dr. Waldorf
says, “I have many patients who have had two to
four Thermage treatments for the face over the
last decade. As the machine has improved, their
results have improved. And it’s been a way for
these patients to put off surgery.”
The device’s latest advancements include the
addition of comfort pulse technology (CPT) to
the Thermage 3 cm2 facial-treatment tip, says
Dr. Waldorf. With CPT, “The handpiece vibrates
to provide a more comfortable experience for the
patient.” Similarly, although the 16 cm2 handpiece
for the body does not vibrate, “because the pulse
rotates among four different pulses, patients can
tolerate it much more easily,” she says.
Dr. Waldorf says the proflle of the device’s RF energy
has changed so that the treatment achieves better
penetration, and there are different size and depth
tips to tailor the treatment. “Patients flnd overall that
it’s more comfortable, and they get faster results.
My patients are uniformly seeing improvement
immediately. Then, just as before, they’re seeing
more improvement over the next six months.”
On the face or body, the amount of improvement
achieved depends on one’s technique and the
number of pulses applied and some patient
variability, she says. “I rarely do focal treatments
and generally recommend that patients have a full
treatment. For the face, I will use 900 pulses with
the 3 cm2 CPT face tip. For the mid-abdomen I
will use the 400-pulse, 16 cm2 body tip.”
If the patient is large, or a smaller patient wants
full abdominal treatment extending around the
hips, Dr. Waldorf says she uses two 16 cm2 tips
total for a total of 800 pulses. Thanks to the
Thermage device’s recent improvements, she says,
“It flnally delivers what it promised — a pain-free
treatment with no downtime that tightens skin.”
“One of the major reasons my patients are so
much happier now than they used to be with the
device is that they have no downtime because they
don’t have to take any pain or anxiety medicine,”
Dr. Waldorf says. Nor do they require injectable
anesthetics, which can cause bruising and swelling, or topical anesthetics, which may be irritating.
After treatment with the Thermage device,
patients experience no redness or swelling, Dr.
Waldorf says. “If a patient has a focal area of
persistent erythema or edema or of purpura, they
should be followed closely. It could be a sign of
a burn. Early topical care will limit permanent
effects. Conflrming that the grounding leads are
intact and the cryogen canister full and using
moderate energies and generous amounts of
coupling fluid can avoid burns.”
Delayed atrophy, reported in the early days of
the technology, was seen in areas of thin skin
and over bony prominences and was likely
due to excessive heating from high energies
and stacking pulses, neither of which is
recommended today, Dr. Waldorf says.
Appropriate patients for Thermage treatments of
the face or body are those who are not physically
and/or emotionally ready for surgery, she says.
For the face, “I often use the device in
combination with flllers, to reduce the overall
volume of flllers the patient will require.” Dr
Waldorf says she explains to patients the plan
using the analogy of fllling a balloon with air: “If
you shrink the balloon, it requires less air.”
CombinaTion opTions Dr. Waldorf says
she also combines Thermage treatments with Fraxel
(Solta Medical) treatments. “The Thermage device
has no downtime. On the other hand, even with the
nonablative Fraxel re:store Dual laser (1,550 nm
and 1,927 nm), patients have two or three days of
signiflcant redness and swelling,” then several days
of dry, dark peeling if one uses the more superflcial
thulium (1,927 nm) wavelength.
If a patient seeks improved
skin color and texture
plus tightening but has
relatively early solar elastosis,
“You can perform one
Thermage treatment to
provide the tightening with
no downtime, then one
Fraxel Dual 1,927 nm
treatment,” Dr. Waldorf says.
If a patient seeks improved skin color and
texture plus tightening but has relatively early
solar elastosis, “You can perform one Thermage
treatment to provide the tightening with no
downtime, then one Fraxel Dual 1,927 nm
treatment,” she says. Conversely, patients with
deeper rhytids and more sun damage will require
several Fraxel treatments.
As for which facial areas she treats, Dr. Waldorf
says, “I see the fastest results with lifting the
jowls and central face, which helps deflne the
jawline and reduce the ‘turkey neck.’ I also
use the device frequently for the upper eyelids
and lateral forehead. I don’t flnd it does a
tremendous amount for the rest of the forehead.
I always tell my patients, ‘This is not a facelift.’”
When treating the body with the Thermage device,
Dr. Waldorf says, “We’re not removing fat or cellulite,
but we are tightening up the skin to hold everything
in better, like wearing a pair of Spanx.” Patients
with post-pregnancy laxity (but not enough to justify
a tummy tuck) or those who believe their skin’s
surface appears too rippled from cellulite tend to be
particularly pleased with the treatment, she says. �
Disclosures:
Dr. Waldorf is a consultant and trainer for Allergan, Medicis and Merz
and a trainer for Solta. Dr. Samlaska is a speaker for Ulthera.
APRIL 2011
23
Gentle handling, minimal processing increase autologous fat graft’s survival rate
Rochelle Nataloni
Quick
read
GETTY IMAGES: FUSE
Newer autonomous fat grafting
techniques and technologies
offer volume retention —
and graft longevity.
S ENIOR S TAFF C ORRESPONDENT
T
he popularity of body
contouring with fat grafts is
growing in direct proportion
to the variety of systems and
techniques employed to accomplish
it. Whether autologous fat transfer
(AFT) is used to repair dents or
dimples resulting from liposuction
or traumatic injuries that leave a
patient’s physique less proportional
than nature originally granted — or
to pump up the volume on small or
ptotic breasts — all fat grafting relies
on a three-step process of harvesting
fat, processing fat and injecting fat.
The distinction — and the outcome
— primarily lies in how the fat is
processed.
Mark Berman, M.D., a fat grafting proponent and private practice
cosmetic surgeon in Los Angeles, says any fat graft will work — at least
temporarily — but how well it works depends on the technique used.
“The more stem cells that are included in the injection, the better
and longer-lasting the results,” Dr. Berman says. He uses the Korean
developed Lipokit system (Medi-Khan), which he says enables him to
maximize his fat-grafting outcomes. The system uses a syringe harvest
technique that concentrates the healthiest fat and stem cells while it
removes most impurities from the harvested fat, and this, he points
out, provides an 80 to 90 percent survival rate of the transplanted fat
grafts.
Fat grafting is probably the most artistically demanding of all surgical
procedures, according to Dr. Berman, but he says the benefit for
surgeon and patient alike is that it gives the patient the
24
opportunity to naturally restore their youthful appearance
without looking “surgical” or even showing the signs of surgery.
COSMETIC SURGERY TIMES
24
AFT
continued
“I like to use fat injections mostly in the face,
but it can be used effectively anywhere in
the body,” Dr. Berman says. “For example,
if someone had a defect in their thigh from
liposuction, you can put fat back into it to
correct that. If they have a defect in their
buttock from an injection of a steroid that
caused a lot of fat atrophy, you can inject
fat back into it and fix it, and likewise, if
somebody had a traumatic injury and lost fat
because of it, you can inject fat back into it to
fix it.”
STEM CELLS AND BLOOD SUPPLY
Dr. Berman says the difference between
AFT grafts that result in limited success and
questionable longevity and those that result in
notable success and indefinite longevity is the
addition of stem cells.
“
There are surgeons who
are freezing the fat, thawing
it and then injecting
it into the breast. We know,
from results reported in
the 1980s, that that
does not work.
Todd K. Malan, M.D.
Scottsdale, Ariz.
”
Todd K. Malan, M.D., of Innovative Cosmetic
Surgery Center, Scottsdale, Ariz., concurs.
“When we were doing regular fat transfer to the
breast, we were happy to get 75 percent overall
fat survival rate, but now that we’re using stem
cells, we’re getting a 95 percent to greater than
100 percent fat survival rate,” Dr. Malan says.
While these surgeons use different processing
techniques, both stress the critical nature of
using as many stem cells as possible in the
graft.
Dr. Malan points out that it is not possible to
actually measure the survival of the fat, so for
instance with breasts, evaluation of fat survival
is based on how big the breasts are before and
after the graft.
“Breast size increases over time in patients
who have fat transfer that’s fortified with
stem cells, whereas patients who have regular
fat transfer get an initial increase and then
stabilization,” Dr. Malan says. “Then at about
three months they end up with about 70
percent fat survival rate, and that’s where they
stay.”
A 55-year-old patient before (left) and two weeks after fat was harvested from the abdomen and hips. The left breast was
injected with 192 cc and the right breast was injected with 276 cc. The patient had several lumpectomies followed by several
implant procedures, and she eventually she opted for stem cell breast augmentation.
(Photos credit: Todd K. Malan, M.D.)
The stem cell-fortified grafts result in “a
dramatic increase in fat storage into the
breast because we’ve significantly improved
the blood supply to the breast,” he says. In
his hands, stem cell-fortified grafts result in
a 70 to 75 percent fat-survival rate at three
months, which increases to about 80 percent
at six months and then 89 percent at nine
months, and then continues to improve,
according to Dr. Malan.
Dr. Malan, who lectures on this topic to
audiences of surgeons worldwide, is a
champion of a stem cell-fortified AFT
technique that protects the fat’s integrity via
minimized processing.
“I use the Cytori Celution (Cytori
Therapeutics) system for harvesting and
activating stem cells,” he says. “The Celution
system has been shown in several multicountry trials to provide dramatic improvement
in fat graft survival.”
He says he also uses Cytori Therapeutics’
PureGraft 250 to prepare the fat. PureGraft
takes 15 minutes to purify a fat graft between
50 mL to 250 mL, removing excess and
unwanted fluid, lipid, blood cells and debris
in a controllable manner, he says. The system
dialyzes everything but the purified fat tissue
without the use of a centrifuge.
“PureGraft allows the transfer of the purest
fat back to a patient, which maximizes the
results,” Dr. Malan says. He stresses that
pure fat offers a better chance for increased
fat survival and a longer life expectancy of
transferred fat, two of the primary concerns
that have plagued the topic of AFT for years.
He also says that he has never had to repeat
a stem cell-fortified breast augmentation.
“I’ve had to do that with normal fat, but
never a stem cell breast augmentation,” Dr.
Malan says. “Every one of our patients has
had greater than 90 percent survival of fat
with stem cells, and we’ve not had to repeat a
single procedure.”
HYPE VS. REALITY Dr. Malan says
there are plenty of naysayers, even within
the cosmetic surgery field, who suggest
that AFT doesn’t work, pointing to their own
unsuccessful outcomes as well as those
reported by others. However, Dr. Malan says,
this criticism is based on outcomes performed
with outdated techniques and technology.
Dr. Malan says it is
not possible to actually
measure the
survival of the fat, so for
instance with breasts,
evaluation of fat
survival is based on how
big the breasts are before
and after the graft.
“There are surgeons who are freezing the fat,
thawing it and then injecting it into the breast.
We know, from results reported in the 1980s,
that that does not work,” he says. “We’re
starting to see patients who had the procedure
done at other facilities where the surgeons
are using techniques from the 1980s, and
they’re not getting good results, which is not
surprising, because it’s old technology.”
APRIL 2011
25
While use of a centrifuge to process fat is
one of the methods that Dr. Malan eschews
as outdated, its use in AFT is still common,
even among surgeons who report remarkable
outcomes, such as Dr. Berman.
Dr. Malan says it’s widely known that spinning
the fat in a centrifuge to remove excess liquid
may harm the fat to some degree, which in turn
may affect the graft’s longevity. Still, surgeons
are willing to take the risk because of the
advantages afforded by ridding the injectable
fat of excess liquid.
While there are gray areas
as far as what processing
methods are best,
according to the literature,
the gentler the fat removal
method and the less
fat is manipulated before
re-injection, the higher
the chances of survival
after transfer.
“They understand that spinning the fat is
going to damage the fat cells, but they think
that the trade-off of getting rid of the water is
worth it,” he says.
Dr. Malan does not use a centrifuge to
process fat and says his results are a
reflection of “looking for any little way we
can to improve the overall fat survival, from
the harvesting to the processing to the
transferring, even if it’s only by 10 percent,
because 10 percent here and 10 percent
there adds up.”
IN SEARCH OF THE BEST
METHODS While there are gray areas as
far as what processing methods are best,
according to the literature, the gentler the
fat removal method and the less fat is
manipulated before re-injection, the higher
the chances of survival after transfer.1 Dr.
Malan says he is currently using a waterjetassisted method of harvesting fat, but he is
also involved in a study to determine if this is
the best method.
“In my hands, it’s far superior to any other
method for getting the best liposuction
results, but from a fat transfer perspective,
it may wash out a lot of the stem cells,
so we are currently involved in a study to
evaluate the stem cell concentrations when
A 54-year-old patient before (top left, top right) and seven months after she had 40 cc of fat grafted to each breast throughout
the superior poles. According to Dr. Berman, they are “still holding up nearly three years later.” (Photos credit: Mark Berman, M.D.)
“
They understand that
spinning the fat is going to
damage the fat cells, but
they think that the tradeoff
of getting rid of the
water is worth it.
Todd K. Malan, M.D.
Scottsdale, Ariz.
”
For instance, he says there is a U.S. surgeon
who was recently reportedly having surgeons
send him fat so that he could process the
stem cells manually and then send the
processed stem cells back for reinjection.
“That’s absolutely against FDA guidelines,”
Dr. Malan says. “All of the surgeons involved
in that chain of events are breaking the rules
and abusing the system, and it’s possible that
this activity will give the FDA an opportunity
to stop the rest of us from doing something
that’s really very beneficial to patients.”
that method is used as compared to other
methods,” he says.
Disclosures:
REGULATION ABUSE Another gray
Dr. Berman is a consultant to Palomar. Palomar recently signed
a distribution agreement with Medi-Khan, manufacturer of the
Lipokit. Dr. Malan reports no relevant financial interests.
area with respect to AFT is approval by the
Food and Drug Administration (FDA). Dr.
Malan says if fat is harvested from a patient
in a doctor’s office and processed with an
automatic device and injected back into the
patient in the doctors’s office, there is no
need for FDA approval of that process. When
surgeons bend these rules, however, the
federal regulatory agency can intervene.
References:
1
Smith P, Adams WP, Lipschitz AH, et al. Plast Reconstr Surg.
2006;117(6):1836-1844.
COSMETiC SURGERY TiMES
26
Most postoperative complications of liposuction are avoidable — or at least
manageable, one expert says
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
Quick
read
Contour irregularities after liposuction
are the most common complication,
but they can usually be improved by
fat shifting or fat transfer. infection is
rare, but potentially devastating, and
mandates prompt intervention. Careful
patient selection is the best way to
avoid liposuction complications.
Dr. Mangubat
A
voidance is the best method
for addressing complications
after liposuction, and that is
usually possible by practicing
careful patient selection and using
proper technique based on appropriate
training and adequate experience, says
E. Antonio Mangubat, M.D., who spoke
at the 27th annual scientific meeting
of the American Academy of Cosmetic
Surgery in January.
Patients who underwent liposuction alone when they really needed
abdominoplasty to remove excess skin account for many of the poor
cosmetic outcomes, whereas the presence of contour irregularities (lumps,
bumps, divots, ridges) is the most common cosmetic complication seen
after liposuction procedures, Dr. Mangubat says.
“Fortunately, serious or severe
complications after liposuction are very
rare, and the most common complications
are cosmetic in nature. Although the
latter can often be treated to achieve a
satisfactory outcome, they are also mostly
preventable in the hands of a well-trained
surgeon,” says Dr. Mangubat, a boardcertified cosmetic surgeon in private
practice in Seattle.
mastering fat disruPtion Dr. Mangubat suggests that more
experienced surgeons — as well as beginners — consider a fat-disruption
technique he introduced several years ago that is effective for enabling
the evacuation of larger volumes of adipose tissue without leaving divots.
The fat disruption technique uses a special cannula (Mangubat Fast-Lipo
Cannula, IMI Beauty and Sound Surgical Technologies) that mechanically
disrupts the fat infrastructure and allows large volumes to be removed
faster using larger cannulas with reproducibly smooth results.
In all cases, good tumescent anesthesia, attention to detail and adequate
experience are critical to minimize poor results. In addition, surgeons
who are early in their liposuction experience should focus on treating
only smaller anatomic areas and removing smaller volumes of fat using
microcannulas.
“I have found the fat-disruption technique to be a valuable adjunct for
ApRil 2011
27
is below 1 percent and the cases usually
involve more minor surgical-site infections
caused by common skin flora. Early detection
and intervention are important, however,
for eradicating the infection and avoiding
progression to a more serious complication.
“Any suspected infection requires prompt
attention. Obtaining a specimen for culture
and sensitivity and beginning empiric antibiotic
treatment is appropriate for what appears to be
a surgical-site infection, but more worrisome
cases, especially if the patient seems ill, need to
be handled aggressively with hospitalization for
a full work-up to identify any serious problems
and initiation of intravenous antibiotics if
appropriate,” Dr. Mangubat says.
For patients suspected to have a minor infection
at the surgical site, Dr. Mangubat empirically
prescribes an antibiotic that covers communityacquired methicillin-resistant Staphylococcus
aureus (CA-MRSA), although he says the
specific agent will vary regionally according to
local susceptibility patterns.
“In the Seattle area, either doxycycline or
trimethoprim-sulfamethoxazole provides very
effective coverage against CA-MRSA,” he says.
A 37-year-old female patient who had undergone liposuction of the thighs (left) and subsequently presented to Dr. Mangubat
with significant cosmetic defects. Repair results are shown (right) six months post-revision liposuction using a fat disruptor
in the scarred areas and fat transfer using a closed-syringe technique adding platelet-rich plasma to the fat grafts.
(Photos credit: E. Antonio Mangubat, M.D.)
training young surgeons in our fellowship
program, because it shortens the learning curve
to achieving good outcomes, and I have received
very positive feedback from other surgeons who
have used it around the world,” Dr. Mangubat
says.
Combating irregularities When
contour irregularities occur, their appearance
can be improved, although they usually cannot
be totally eliminated to achieve a perfectly
smooth surface. Intervention involves a multiplestep process.
After marking the depressed areas and injecting
tumescent anesthetic, the surgeon can use the
fat-disrupter cannula to break up the fat and
fibrosis. This will result in an almost-immediate
improvement of the defects, but not full
correction. Further smoothing is accomplished
with fat-shifting and fat-transfer techniques.
For fat shifting, after disrupting the fat in
both the elevated and depressed areas, the
surgeon can try to relocate the fat by applying
mechanical pressure on elevated areas, forcing
the freed-up fat to ooze into the depressed
regions. However, fat transfer offers greater
control for contouring and therefore is a more
reliable method for achieving good results, Dr.
Mangubat says.
To perform fat transfer, after disrupting the fat
and fibrosis into an emulsified layer, the surgeon
uses a small fat-harvesting cannula to remove
excess fat from the elevated areas. The fat is
harvested into a syringe, processed for transfer
and injected into the depressed areas.
“If the fat and fibrosis was adequately disrupted,
the depressions will rise up nicely in response to
the fat injection. Otherwise, it may be necessary
to reintroduce the fat disrupter to release more
of the scarring, or in some cases to free it by
cutting with scissors,” Dr. Mangubat says.
He says any intervention to address irregularities
should not be attempted for at least three
months in order to allow for some healing and
scar-tissue maturation. If the patient is willing,
he says, waiting six months is even better.
infeCtion ConCerns Infection is one
of the most potentially serious complications
of liposuction. Dr. Mangubat says in his
practice, the post-liposuction infection rate
building skill Although recent
innovations involving laser or ultrasound-based
lipolysis have been touted by manufacturers as
superior to traditional tumescent liposuction for
fat removal and body contouring, proper training
and adequate experience — not new technology
— are the elements for surgical excellence, Dr.
Mangubat says.
“The critical element in the success of
liposuction is the skill of the sculptor. One can’t
give novices a set of brand new tools and expect
them to carve Michelangelo’s David on the first
attempt,” he says.
“There are multiple techniques for performing
liposuction, and surgeons need to find the one
that works best for them, but they also need to
get the right training and gain experience. In
this regard, the American Academy of Cosmetic
Surgery and many of its members have a lot
to offer in learning opportunities, including
fellowships, mentorships and live surgery
workshops,” he says.
Dr. Mangubat encourages all surgeons to
take advantage of these essential educational
opportunities. Physicians learning the
procedures get personalized education from
many of the world’s experts, he says. �
Disclosures:
Dr. Mangubat reports a proprietary interest in the Mangubat Fast-Lipo
Cannula.
COSMETiC SUrGErY TiMES
28
High-definition liposculpture attracts males to cosmetic surgery now more than ever
Rochelle Nataloni
Quick
read
S ENIOR S TAFF CORRESPONDENT
GETTY IMAGES: SAMI SARKIS
Males represent a significant — yet
largely untapped — population for
cosmetic surgeons. One physician
describes his marketing initiatives
that attract men to his practice.
Dr. Millard
S
ignificantly more women than
men seek cosmetic surgery,
and savvy surgeons who
choose to see the potential
in these data recognize that the male
population represents a huge, almost
entirely untapped market. Denver
cosmetic surgeon John Millard, M.D.,
who says two-thirds of his patients are
men, is among that group of forwardthinking practice owners who are
actively marketing their services to
males.
“We market six-pack abs as part of our
search terms in our online promotional
efforts,” Dr. Millard says, “and highdefinition liposculpture, with either
VASER (Sound Surgical Technologies) or
Smartlipo (Cynosure), is the procedure
that is bringing men in by the droves. I’ve had men fly in from 21 countries
and 47 states to have these procedures.”
Cosmetic surgeons such as Dr. Millard, who have a considerable proportion
of male patients among their clientele, say the number of men interested
in and seeking body-contouring procedures is increasing exponentially.
Surgeons interviewed for this article say the remarkable outcomes possible
with high-definition body sculpting, combined with the pressures of a
society that generally rewards a healthy, youthful appearance and the
toll that metabolic changes take on middle-aged men — no matter how
fastidious they are about diet and exercise — all prompt males to seek
such services.
Dr. Millard, who pioneered high-definition liposculpture in the United States,
describes it as an adjunct to one’s fitness regimen. “I sculpt the abs, the pecs,
the biceps, the triceps, almost every muscle that people work at the gym — I
sculpt surgically. When I sculpt those muscles, I leave a little bit of extra fat
over the muscle areas to enhance definition,” he says. Dr. Millard says almost
everyone has that definition, but on most people it’s hidden by fat.
April 2011
29
In his practice, high-definition liposculpture
typically attracts patients with a BMI of 25,
although 22 or lower isn’t uncommon, whereas
traditional liposuction tends to attract people
with a BMI closer to 30.
“High-definition liposculpture opened up a
whole new patient demographic for me,” Dr.
Millard says. “I’ve got several patients who are
former professional athletes, and even some
who are body builders. Some of these patients
have worked on their body their whole life but
have never been able to shred down.
“
High-definition
liposculpture is bringing
men in by the droves.
John Millard, M.D.
Denver
”
“To attain muscle definition by dieting and
lifting weights, you have to shred down to
about 5 percent body fat, which is not possible
without severe food restrictions,” Dr. Millard
says. He says he tells his patients that the
combination of high-definition liposculpting
along with diet and exercise enables them to
have a “six pack” — and a steak.
“They can actually eat reasonably and still
maintain that lower fat percentage,” Dr. Millard
says. “The body parts that we sculpt have
a lower fat percentage, but their total body
fat percentage is healthier — still in the 12
percent to 15 percent range, which is where
most people who work out and take care of
themselves are.”
Give them what they want Robert
A. Shumway, M.D., of La Jolla, Calif., whose
patient base is 20 percent male, says those who
present seeking body sculpture come from a
couple of different camps.
“It’s kind of bimodal. There is the group that
has not done a good job of taking care of
themselves and they’re disgusted with the
overall result. Then there’s another group of
people who are really fastidious and perhaps
even compulsive and are looking for results
that are not reasonably achievable,” he says.
“These people have to be counseled as far
as what we can realistically accomplish. They
need to understand that what we can do is
simply improve what they already have.”
Dr. Shumway says there are three methods
by which he helps to fulfill the most common
requests of his male patients: liposculpting, fat
grafting and implants. He says liposculpting is the
procedure most frequently requested.
fashion.” He says he likes to use lasers in areas
where it’s helpful to have some skin tightening.
“When male patients present, they are
concerned mostly about their middle region,
which includes the love handles and the fatty
deposits in the abdomen,” Dr. Shumway says.
“One of the most important things that we
can do as physicians is to make sure that
men are on an appropriate diet and exercise
regimen and that they’re healthy, and that if
they undergo liposculpting, they realize that
it’s a partnership between the physician, the
physician’s practice and the patient.
“Lasers are handy for the upper extremities
and perhaps areas in the lower and upper
abdomen where you need to get more contour
or tightening. No particular wavelength has
been reported to be better than another for
this purpose, but it is important to have a
uniform fluence,” Dr. Shumway says.
“So, if they’re obese or overweight, we try to
set realistic expectations and sometimes help
them get their weight under control first and
get a healthy lifestyle, including cessation
of smoking and alcohol consumption, if it’s
excessive,” he says. “We also help them lose
fat that is inside and around their intestines,
which cannot, of course, be liposculpted out.”
“
High-definition
liposculpture opened
up a whole new patient
demographic for
me. I’ve got several patients
who are former professional
athletes, and even
some who are body builders.
Some of these patients
have worked on their body
their whole life but have never
been able to shred down.
John Millard, M.D.
Denver
”
Dr. Shumway chooses the modality — laser
liposuction, power-assisted liposuction, waterassisted devices — depending on the location
of the fat and the patient’s desires.
“When I’m working in the upper abdomen,
power devices, such as Sound Surgical’s
Power-X works well, and another device that I
have great success with in extremely fibrous
areas is KMI’s Starr,” he says.
When he wants to remove large areas of fat and
retain some of it for reinjection in other places, Dr.
Shumway says water-assisted devices work well
and can be used to extract fat “in a very clean
“
I’ve seen a dramatic
increase in men requesting
gluteal augmentation.
John Millard, M.D.
Denver
”
Dr. Shumway says he also gets good results
with the low-frequency ‘Tickle Lipo.’ “It is
very effective at breaking up fat, patients get
a little bit better sculpted and the healing is a
bit quicker, as well,” he says.
Drs. Millard and Shumway say that while
well-defined abs are by far the most frequent
request, men are increasingly seeking to
improve a droopy derriere as well.
“I’ve seen a dramatic increase in men
requesting gluteal augmentation,” Dr. Millard
says. He says he has developed a technique
to address this concern. “We’ve come up with
a male version of the Brazilian buttlift that
combines high-definition sculpting and fat
grafting that is very effective.”
Dr. Millard’s technique, which aims to enhance
the musculature look of the rear, relies on
transplanting the fat a little more laterally
than would typically be done in a female
patient. “This way we get that nice dimple on
the side,” he says.
Road to RecoveRy Dr. Millard says
his average male patient is back at the gym
after two to three weeks. “We’ve pioneered
something called post-lipo CARE. CARE
stands for Cosmetic Active Recovery, and
is a combination of lymphatic drainage and
external ultrasound, radiofrequency and a
diode laser and it decreases a lot of postop
swelling,” he says. “We’ve been able to cut
recovery down by approximately 50 percent.
My patients who are between 20 and 40 can
be back in the gym in two weeks; for my 40to 65-year-old patients, it’s more like three
weeks.” �
Disclosures:
Dr. Shumway reports no relevant financial interests. Dr. Millard is a
consultant to VASER and SmartLipo.
COSMETIC SURGERY TIMES
30
With proper patient selection, large-volume and megaliposuction
can be safe, satisfying
Quick
read
GETTY IMAGES: EBBY MAY
Megaliposuction (fat aspiration
>10,000 cc) and large-volume
liposuction (fat aspiration
4,000 cc to 10,000 cc) are safe
procedures when performed
without general or tumescent
anesthesia and when patients are
carefully selected and monitored.
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
APRIL 2011
31
M
egaliposuction targeting multiple
body sites can provide rewarding
results for patients who are
morbidly obese and resistant
to undergoing bariatric surgery. These
procedures can be very safe when performed
with the involvement of an expert team to
ensure appropriate patient selection and
management, according to Jose Salas, M.D.,
who spoke at the International Society of
Cosmetogynecology workshop held before
the 27th annual scientific meeting of the
American Academy of Cosmetic Surgery
(AACS) in Phoenix in January.
“In the past, I would refuse
to perform liposuction in
patients who I felt would be
better served by referral to a
bariatric surgeon. However,
some individuals do not
want to undergo bariatric
Dr. Salas
surgery, and for those
patients, liposuction can
have an important role in improving their
physical appearance and self-esteem,” says
Dr. Salas, a board-certified cosmetic surgeon
and director, Clinica de Cirugia Cosmetica,
Tijuana, Mexico.
“
Certainly, there are
potential risks, and they
are all explained in the
informed consent, and the
final cosmetic outcome in
these cases does not
match that achieved when
less-extensive liposuction
procedures are performed
for body contouring in
persons who are not obese.
Jose Salas, M.D.
Tijuana, Mexico
”
“Certainly, there are potential risks, and they
are all explained in the informed consent,
and the final cosmetic outcome in these
cases does not match that achieved when
less-extensive liposuction procedures are
performed for body contouring in persons
who are not obese,” he says. “However, with
my approach, megaliposuction and largevolume liposuction have been very safe; they
may even sometimes be combined with other
surgeries, and the patients who’ve undergone
these procedures are uniformly happy with
the result.”
DEFINITIONS, DEFINED
Dr. Salas notes that the
definition for megaliposuction
varies. For example, the AACS
classification considers it
megaliposuction when more
than 5,000 cc are removed,
but according to his personal
classification system, Dr.
Salas considers large-volume
liposuction to be procedures
involving 4,000 cc to
10,000 cc of fat removal and
megaliposuction to be cases in
which than 10,000 cc of fat is
aspirated. In a review of nearly
200 liposuction cases he
performed in 2008, he found
that 34 percent were largevolume procedures and
2.5 percent were
megaliposuction cases.
Before (top) and approximately two-and-a-half years after Brazilian buttlift
(buttocks fat grafting), during which 900 cc were transferred to each buttock
(480 cc subdermal, 420 cc submuscular). (All photos credit: Jose Salas, M.D.)
SCREENING FOR
SAFETY Appropriate
patient selection and careful
monitoring during the
procedure are paramount for
safety in the large-volume and
megaliposuction procedures.
Patients are only considered
candidates if they are in
good health as determined
by a careful preoperative
Before (top) and approximately
i
two-and-a-half years after large-volume
evaluation that includes
liposuction of the abdomen, waist and back, during which 4,800 cc of fat were
comprehensive laboratory
aspirated (2,200 cc anterior/2,600 cc posterior).
testing and examination by a
SURGICAL TECHNIQUE Dr. Salas
cardiologist for patients age
says he uses neither general nor tumescent
40 years and older. During the procedure,
anesthesia when performing large-volume
an anesthesiologist is on hand to monitor
and megaliposuction procedures. Rather,
systemic functions, including oxygen
patients are given an epidural block and the
saturation, pulse rate, blood pressure,
targeted areas are infused with a solution
respiratory rate and urine output.
prepared by adding 1 mL of adrenaline
1:1000 (1 ampule) to 1 L of normal saline.
The resulting solution is injected using an
infiltration cannula of 2 mm diameter and
30 cm length and infiltration pump, and a
volume of 4 L is infused on average in both
large-volume and megaliposuction cases.
Once the solution has been infused in a
particular anatomic region, Dr. Salas waits
at least 20 minutes to make sure there is
adequate vasoconstriction before beginning
the liposuction.
Dr. Salas uses neither general
nor tumescent anesthesia
when performing largevolume and megaliposuction
procedures. Rather, patients
are given an epidural block
and the targeted areas are
infused with a solution
prepared by adding 1 mL of
adrenaline 1:1000 (1 ampule)
to 1 L of normal saline.
Fat aspiration from premarked areas is performed
using various size cannulas (4 cm, 5 cm and
6 cm) and a suction pressure of 1 atm.
CONCOMITANT PROCEDURES
Dr. Salas also notes that some
32
GETTY IMAGES: EBBY MAY
COSMETIC SURGERY TIMES
32
Mega
continued
patients who are undergoing large-volume
liposuction may benefit from using the
aspirated fat for autologous grafting, such
as for augmentation of the breast, buttocks
and/or face.
“
During the preoperative
consultation, it is important
to inform patients
that the fat being removed
contains live cells that
can be used as a graft
to improve the overall
outcome of their body
contouring procedure.
Jose Salas, M.D.
Tijuana, Mexico
”
“During the preoperative
consultation, it is important to
inform patients that the fat being
removed contains live cells that
can be used as a graft to improve
the overall outcome of their body
contouring procedure,” Dr. Salas
says.
In addition to fat
transfer, patients
may also undergo
additional body
contouring at
Before (top) and approximately six months after megaliposuction of abdomen,
waist, arms and lower back, during which 13,400 cc of fat were aspirated
the same time
(9,500 cc anterior/3,900 cc posterior).
as large-volume
In addition to fat transfer, patients may
liposuction, such as
also undergo additional body contouring at
the same time as large-volume liposuction,
abdominoplasty, breastlift
such as abdominoplasty, breastlift or breast
or breast augmentation.
augmentation. APRIL 2011
33
Assay standardization can advance autologous-fat-graft research, clinical use
Cheryl Guttman Krader
Quick
read
S ENIOR S TAFF CORRESPONDENT
GETTY IMAGES: INGRAM PUBLISHING
Use of standardized assays for
assessing autologous fat grafts
is needed for valid scientific
comparisons of different techniques
for fat harvesting, processing and
delivery to determine optimal clinical
results. Maurice P. Sherman, M.D.,
proposes testing methodologies.
Dr. Sherman
U
se of a set of standardized
assays for characterizing
the biologic parameters of
autologous fat grafts (AFGs)
should facilitate the identification of
fat-transfer techniques that provide
optimal outcomes. Additionally, it may
provide a basis for encouraging more
widespread adoption of autologous fat
grafting as a technique for soft-tissue
repair, augmentation and reconstruction,
according to Maurice P. Sherman, M.D.
Dr. Sherman, a private practitioner
specializing in cosmetic, facial plastic
and reconstructive surgery at Del Mar
Cosmetic Medical Center, Del Mar,
Calif., provides a rationale for developing
standardized methods for AFG analysis
by outlining the various factors that
potentially can affect AFG quality and
longevity and evaluating these variables within the laboratory setting utilizing
such a standard AFG assay.
“Multiple variables in AFG technique can contribute to the disparate results
that have been reported for long-term graft retention. Those differences,
together with variability between studies in the methods used for evaluating the
biological parameters of fat grafts, confounds our ability to make inter-study
comparisons of outcomes,” says Dr. Sherman, who is also associate clinical
professor of surgery, University of California, San Diego.
“Implementation of a core set of analytical tools in combination with a
common understanding of fat-graft anatomy and physiology should allow
us to identify approaches that can yield the best clinical results. It would
allow valid, scientific comparisons of how specific variables — including new
fat-harvesting technologies and tissue-processing techniques — affect AFG
safety and efficacy,” Dr. Sherman says. “The standardized assay can also be
implemented in research aimed at understanding how new technologies affect
adipose regenerative cell safety and efficacy. Looking farther ahead, it may
enable research to discover new biomarkers for identifying patients who would
more likely benefit from fat grafts enhanced with stem cells processed from
additional harvested fat.”
34
COSMETIC SURGERY TIMES
34
Assay
continued
VARIABLES IN OUTCOMES Differences
in donor characteristics as well as in methods for
tissue acquisition, processing and delivery may all
affect the AFG characteristics and the results of
the fat-transfer procedure.
GETTY IMAGES: STEVE GSCHMEISSNER
For example, variables in fat harvesting that may
affect graft characteristics include the size and
style of the cannula, wetting-solution composition,
degree of suction and type of mechanical force/
energy used (ultrasound-, water- or power-assisted).
Similarly, graft characteristics may potentially be
affected by the differing processing techniques,
such as sedimentation, washing, centrifugation and
straining. Use of different cannula types, variations
in volume placed per stroke and site of AFG
deposition are other variables in graft delivery that
may influence the outcome.
“
Although the term
‘ADRCs’ refers to all
therapeutically relevant cells
found in the adipose stromal
vascular niche, adipose
stem cells make up only
1 to 5 percent, while other
cell types predominate.
Maurice P. Sherman, M.D.
Del Mar, Calif.
”
“Currently, there is only anecdotal evidence
about the relative effects of different methods
of fat harvesting, processing and delivery on
AFG outcomes, but no real scientific data, and
so we don’t know if certain techniques are best.
Nor do we know whether fat can be adequately
cryopreserved,” Dr. Sherman says.
BASIS FOR STANDARDIZATION
Dr. Sherman says efforts toward AFG assay
standardization have been made in the past, but
they have been suboptimal because they lacked
sufficient specificity.
“Historically, the research has focused on the
whole graft as mainly numbers of adipocytes.
However, the whole graft has other physical
qualities to consider in terms of its aqueous and
lipid content, and the adipocytes need to be
described in percent cell viability,” Dr. Sherman
says.
“Understanding of the entire adipose graft at the
cellular composition level is also key to increasing
successful graft outcome,” he says. “Research
must acknowledge that the fat-graft components
include intact clusters of adipose tissue as well
as disrupted tissue representing blood and
microvascular cells, the wetting/tumescent
solution, free lipids and the extracellular matrix that
includes adipose stem cells plus other regenerative
cells (the stromal vascular fraction). This is the
‘niche’ that holds the clusters of fat cells together,
much like the stem holds together a cluster of
grapes.”
It is also known that there are interdonor
differences in the concentration and composition
of the stromal vascular cells (nonadipocyte cell
population) in AFGs.
Studies assessing density of these adipose-derived
regenerative cells (ADRCs) in human fat grafts
show a bell-shaped distribution wherein the density
of these cells is very high in only about 10 to
15 percent of the population, but minimal in the
fat graft specimens of about 10 percent of the
population.
“We know stem cells can have a role in
differentiation, angiogenesis, wound remodeling,
immune modulation and apoptosis. Perhaps
patients with higher ADRC content in their grafts
may have an excellent take rate without further
manipulation of the graft, whereas those with
a low ADRC content may benefit from graft
enhancement,” Dr. Sherman says.
“Although the term ‘ADRCs’ refers to all
therapeutically relevant cells found in the adipose
stromal vascular niche, adipose stem cells make
up only 1 to 5 percent, while other cell types
predominate,” he says. “We need to determine the
specific identity of stromal vascular cells present in
the fat graft and the percentage of each type and
understand how variables in AFG technique affect
these various cell types within the stromal vascular
fraction.”
AFG ASSAY Dr. Sherman proposes that a
standard AFG assay should include seven factors:
• fat content, water content and free-lipid content
(the physical characteristics of the graft);
• adipocyte health (fat-cell viability) using the
glycerol release test;
• stromal vascular cell numbers by automated
nuclei counting;
• stromal vascular cell composition with flow
cytometry and histology; and
• stromal vascular cell viability with trypan blue.
“Trypan blue and the MTT assay are also used to
assess fat-cell viability, but the glycerol release
test is easier, less expensive, more accurate
and more reproducible. For determining stromal
vascular cell viability, trypan blue is currently the
best technique, but it is really suboptimal for that
purpose because it has an unacceptably high false
positive rate,” Dr. Sherman says.
“Nonetheless, standardization of the AFG assay
would provide a foundation to compare studies in
a cohesive manner, and this proposed set of tests
would provide researchers as well as developers
of new technology a chance to speak the same
language in comparing techniques, evaluating
variables and analyzing results.”
Disclosures:
Dr. Sherman reports no relevant financial interests.
B R E A S T
F A C E
Ilya Petrou, M.D.
S ENIOR S TAFF CORRESPONDENT
Dr. Dayan
GETTY IMAGES: PANDO HALL
Quick
read
Fillers can be very effective
when performing a nonsurgical
rhinoplasty. In order to maximize
aesthetic outcomes and avoid
complications, however, the
physician must choose the right filler
and have in-depth knowledge of the
anatomy and physiology of the nose.
C HICAGO — Rhinoplasty has long been
a cornerstone surgical procedure
performed by cosmetic and plastic
surgeons in patients who desire
aesthetic correction of the nose.
And recently, innovative fillers with
increasingly versatile indications
have been found to be useful as a
nonsurgical approach for rhinoplasty.
As this indication is gaining popularity
in the aesthetic arena, one expert
advises fellow surgeons to carefully
choose the filler used and maintain an
in-depth knowledge of the anatomy and
physiology of the nose. These are key to
achieving excellent aesthetic outcomes
and avoiding complications, he says.
“I believe the best results of rhinoplasty
can still be achieved with surgery.
However, there are those cases where a
nonsurgical approach using fillers can
43
achieve immediate aesthetic results,
35
APRIL 2011
B O D Y
COSMETIC SURGERY TIMES
|
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PRODUCTS & SERVICES
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INCLUDES PRP
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california
Practice For Sale
Los Angeles, CA
Long established cosmetic surgery practice
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Modern, attractive 2100 sq.ft facility with
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Retiring seller will assist with transition.
Call
equipment for sale
FOR SALE
2008
2008 MiXto
MiXto SX
SXFractional
FractionalLaser........$25,000
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2003 Sciton Profile Laser................$25,000
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2006 Sciton
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Institute of Aesthetic Surgery
Maggie Trudeau 407-303-4368
[email protected]
georgia
800-416-2055
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PRODUCTS & SERVICES
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B R E A S T
F A C E
Nonsurgical continued
and in some patients, fillers may be a solution
for the aesthetic correction of a nose deformity,”
says Steven H. Dayan M.D., F.A.C.S., a facial
plastic and reconstructive surgeon in Chicago.
Many different fillers can be used in the
nonsurgical procedure, including silicone,
hyaluronic acid products such as Juvéderm
(Allergan) and even autologous fat injections.
However, according to Dr. Dayan, Radiesse
(calcium hydroxylapatite, BioForm/Merz) and
Restylane (hyaluronic acid, Medicis) are two
of the best fillers for this indication.
A nonsurgical approach could be an option
in a patient who is either apprehensive of
surgery or where surgery is contraindicated
due to financial or medical issues.
“Some patients may want a little correction
of a small irregularity, but surgery may seem
too much of a heroic effort for the cosmetic
correction to be made. Fillers would be an
option here and can be very effective when used
sparingly and placed strategically,” says Dr.
Dayan, who recently spoke at the 6th Annual
Facial Cosmetic Surgery meeting in Las Vegas.
A patient with saddle nose deformity 12 months post-rhinoplasty/septoplasty (left), and with the irregularity corrected (right)
three months after placement of 0.6 cc of Radiesse/1 percent lidocaine with epi mixture supraperiosteal, resulting in a
smooth dorsum. (Photos credit: Steven H. Dayan, M.D., F.A.C.S.)
the technique is too frequently chosen by
surgeons who attempt to recreate the results
of a surgical rhinoplasty. Doing so can result
in many complications, including impending
necrosis, necrosis and subsequent scarring,
as well as hypersensitivity and infections.
INDICATIONS With sufficient volume
injected just above the radix, Restylane or
Radiesse can often be effective in correcting
a large dorsal convexity of the nose, masking
the deformity. In these patients, the nose
often needs to be balanced, and by adding
volume with a filler, a bigger nose can appear
smaller and achieve an improved aesthetic
proportion to the face. According to Dr.
Dayan, the cosmetic correction can last
approximately nine months to one year using
either Radiesse or Restylane.
Another indication could be in patients with
a near-miss rhinoplasty, where, according
to the patient, the nose only has a slight
imperfection to be corrected (such as a slight
localized depression or other irregularity).
Using 0.1 cc to 0.2 cc of either Restylane
or Radiesse in these cases can result in
cosmetic outcomes lasting three to four years.
“This longevity may not be entirely due
to the filler itself but also due to the
product’s ability to induce neocollagenesis
in the targeted area,” Dr. Dayan says. “This
can effectively fill out the depression or
irregularity and mask the cosmetic flaw.”
Nonsurgical rhinoplasty has its place and
should only be performed in carefully
selected patients. According to Dr. Dayan,
If a physician gives too much filler or
erroneously places it intravascularly,
impending necrosis or frank necrosis can
quickly occur. Infections can also be a
common and serious complication following
a nonsterile injection or too many injections,
particularly in this region.
AVOIDING COMPLICATIONS To help
avoid or reduce the risk of infections, Dr.
Dayan suggests a meticulous cleansing of
the nose using benzalkonium chloride (not
alcohol) or betadine as a second choice.
Moreover, the surgeon should perform as few
injections as possible and strategically inject
small quantities of filler deep onto the bone
or nasal skeleton below the SMAS. Dr. Dayan
also stresses the importance of diluting the
filler with lidocaine, because by decreasing
the viscosity, one can decrease the vascular
congestion and reduce the risk of impending
necrosis and necrosis.
“I use these fillers mostly in the upper twothirds of the nose and try to stay away from
the nasal tip because of the higher risk of
necrosis resulting from vascular congestion in
the soft tissues. Most of the cases of impending
necrosis or necrosis following filler treatments
occur in the lower third of the nose,” Dr. Dayan
says.
Dr. Dayan refrains from using Juvéderm in
the nose due to its hydrophilic nature. This
characteristic can cause localized expansion
and edema, and though this may be beneficial
when addressing deep nasolabial folds, it
may increase the risk of vascular congestion,
especially when used in the lower third of
the nose. This may lead to necrosis and/or
suboptimal aesthetic outcomes, he says.
MANAGING COMPLICATIONS Dr.
Dayan says when he encounters an impending
necrosis, he immediately stops injecting,
massages the area and then injects 10 to 30
units of hyaluronidase, regardless of the filler
used. The hyaluronidase will not only break
down the product (in the case of hyaluronic
acid), it will also reduce local edema. He then
applies topical nitropaste to the area and
gives the patient an aspirin.
A reticular pattern appearing at the injected
site is a typical sign of vascular congestion.
In these cases, Dr. Dayan says he suggests
starting the patient on oral and topical
steroids and asking the patient to return for
follow-up until the complication subsides.
“I think an adequate training and clear
protocols concerning this technique are
lacking, because I have been seeing too many
referrals with too many procedure-associated
complications. Knowing the dynamics of
fillers and how they can impact the anatomy
and physiology of the target area is crucial in
avoiding complications,” Dr. Dayan says. Disclosures:
Dr. Dayan receives research support grants from Allergan, Medicis and
BioForm/Merz.
43
APRIL 2011
B O D Y
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©2011 Palomar Medical Technologies, Inc. Palomar and is a registered trademark and SlimLipo is a trademark
of Palomar Medical Technologies, Inc. ALL RIGHTS RESERVED.
Palomar Medical Technologies, Inc. 15 Network Drive, Burlington, MA 01803 USA
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www.palomarmedical.com USA: 1-800-PALOMAR