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Ultrasound-Assisted
Liposuction

Current Concepts
and Techniques
Onelio Garcia Jr.
Editor

123
Ultrasound-Assisted Liposuction
Onelio Garcia Jr.
Editor

Ultrasound-Assisted
Liposuction
Current Concepts and Techniques
Editor
Onelio Garcia Jr.
Division of Plastic Surgery
University of Miami
Miller School of Medicine
Miami, FL
USA

ISBN 978-3-030-26874-9    ISBN 978-3-030-26875-6 (eBook)

https://doi.org/10.1007/978-3-030-26875-6

© Springer Nature Switzerland AG 2020

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I have been very fortunate to have people in my
life who believe in me and support my career. I
wish to dedicate this book to them.

To my parents, Dr. and Mrs. Onelio Garcia Sr.,

who somehow envisioned that their 18-year-old
surfer would attend college and then pursue a
career in medicine.

To my children, Sloane, Alana, Brysen, and Spencer.

They are my greatest source of pride. I have no
doubt that they will all accomplish far more in their
respective fields than I ever will in mine.

To my professor and mentor Dr. Bernard L. Kaye,

a founding member and past president of the
American Society for Aesthetic Plastic Surgery.
Those of us who enjoyed the privilege of training
under him learned far more than plastic surgery
from a genuine “Renaissance Man.”

To my contributing authors. Their contributions

have greatly enhanced this book and I am
extremely grateful for the time and commitment
they invested in this project.

To my longtime associate Dr. Jose Perez-Gurri, a

contributing author in this book. After a third of
a century, I still find enjoyment in us working
side by side and discussing the occasional
interesting case. What an amazing experience it
has been!

To Isabel who has defined for me unconditional

love and devotion. I am so very grateful that you,
for one, understand the demands of my career
and support it.

To my patients. It has been my privilege to have

been entrusted with your care.

Onelio Garcia Jr.

Preface

It has been over 20 years since Rohrich, Beran, and Kenkel wrote their acclaimed
textbook, Ultrasound-Assisted Liposuction. The book served our specialty well. It
was a comprehensive, concise reference which covered all the important topics
associated with what was then a new and exciting technology for plastic surgeons.
Since that time, we have developed a better understanding of the dynamics of
internal ultrasound for body contouring and its effect on adipose tissue. The current
ultrasound devices for liposuction are safer and more efficient than the previous
generations. This textbook is intended to bridge the gap between the early days of
ultrasonic liposuction and the present. The contributing authors are all well-­
respected experts in the field who share their extensive experience with the new
ultrasound technology. It is my sincere intention that this book will serve as a refer-
ence in ultrasound-assisted liposuction for years to come.

Miami, FL, USA  Onelio Garcia Jr.

vii
Acknowledgment

A special thanks to Dr. Paola S. Chaustre from the Imagos Institute of Plastic
Surgery for her tremendous assistance with the medical photography for this
project.

ix
Contents

Part I Fundamentals
1 Ultrasonic-Assisted Liposuction: Introduction
and Historic Perspectives������������������������������������������������������������������������    3
Mark L. Jewell
2 Basic Science of Ultrasound in Body Contouring ��������������������������������    9
Mark E. Schafer
3 Choosing the Correct Candidate������������������������������������������������������������   23
Jose A. Perez-Gurri
4 Anesthesia and Wetting Solutions����������������������������������������������������������   37
Onelio Garcia Jr.

Part II Clinical Applications

5 Neck and Facial Contouring ������������������������������������������������������������������   49
Onelio Garcia Jr.
6 Contouring of the Trunk ������������������������������������������������������������������������   65
Onelio Garcia Jr.
7 VASER-Assisted Liposuction of Gynecomastia������������������������������������   87
Onelio Garcia Jr.
8 Contouring of the Extremities����������������������������������������������������������������   99
Onelio Garcia Jr.
9 Aesthetic Contouring of the Buttocks���������������������������������������������������� 133
Onelio Garcia Jr.

xi
xii Contents

Part III Special Applications

10 ultraBBL: Brazilian Butt Lift Using Real-­Time
Intraoperative Ultrasound Guidance ���������������������������������������������������� 147
Pat Pazmiño
11 Ultrasonic Treatment of Silicone Injection Complications������������������ 173
Katherine H. Carruthers, Carissa L. Patete, and
Christopher J. Salgado
12 Ultrasound-Assisted Liposuction in the Massive
Weight Loss Patient �������������������������������������������������������������������������������� 189
Dennis J. Hurwitz
13 High-Definition Body Contouring Using VASER-Assisted
Liposuction ���������������������������������������������������������������������������������������������� 203
Alfredo E. Hoyos and David E. Guarin
14 Ultrasound-Assisted Liposuction: Medicolegal Considerations���������� 213
Neal R. Reisman
Index������������������������������������������������������������������������������������������������������������������ 221
Contributors

Katherine H. Carruthers, MD, MS West Virginia University, Department of

Surgery, Division of Plastic Surgery, Morgantown, WV, USA
Onelio Garcia Jr., MD Division of Plastic Surgery, University of Miami, Miller
School of Medicine, Miami, FL, USA
David E. Guarin, MD Universidad del Valle, Hospital Universitario del Valle,
Department of Plastic Surgery, Cali, Valle del Cauca, Colombia
Alfredo E. Hoyos, MD Private Practice, Bogotá, Colombia
Clinica Dhara, Department of Plastic Surgery, Bogota, Colombia
Dennis J. Hurwitz, MD Hurwitz Center for Plastic Surgery, Pittsburgh, PA, USA
University of Pittsburgh, Pittsburgh, PA, USA
Mark L. Jewell, MD Oregon Health Science University and Private Practice,
Portland, OR, USA
Carissa L. Patete, BS Miami, FL, USA
Pat Pazmino, MD University of Miami, Division of Plastic Surgery, Miami, FL,
USA
MiamiAesthetic, Miami, FL, USA
Jose A. Perez-Gurri, MD, FACS Florida International University, Herbert
Wertheim College of Medicine, Miami, FL, USA
Neal R. Reisman, MD, JD, FACS Baylor College of Medicine, CHI Baylor St.
Luke’s, Department of Plastic Surgery, Houston, TX, USA
Christopher J. Salgado, MD Miami, FL, USA
Mark E. Schafer, SB, MS, PhD Sonic Tech, Inc., Lower Gwynedd, PA, USA

xiii
 Part I
Fundamentals
Chapter 1
Ultrasonic-Assisted Liposuction:
Introduction and Historic Perspectives

Mark L. Jewell

It’s 2019 and suction-assisted lipoplasty (SAL) has been around in America for
almost 35 years. Without chronicling each advance in this technology, one can say
that this has become a mature, yet integral surgical technology for thinning of sub-
cutaneous adipose tissue (SAT). Lipoplasty has evolved into a sophisticated tech-
nique for 3D body contouring, harvesting of fat for grafting, and as a complimentary
procedure with excisional body contouring (lipoabdominoplasty). I credit much of
this to advances in technology over the years. On the other hand, there are many
surgeons performing this procedure poorly with 30-year-old cannulas and no pro-
cess to produce great results. Poor aesthetic outcomes continue to this day because
some surgeons lack a process to produce great outcomes or have ill-defined subjec-
tive clinical endpoints during the procedure. Lipoplasty is not an all-comers proce-
dure where poor decisions made in terms of patient selection produce poor aesthetic
outcomes and patient dissatisfaction.
The concept of an energy-based lipoplasty device to enhance the ability of the
surgeon to be more precise with the reduction of SAT or to modulate the mid-
lamellar collagen matrix is perfect for ultrasonic energy versus other heat-emitting
technologies (laser and radiofrequency). A variety of approaches have been tried,
some very effective and others relegated to the medical device trash bin. Each of
these has specific limitations and nuances. When choosing an energy-based lipo-
plasty device, the surgeon must surround himself/herself with a process to produce
reproducible outcomes time and time again.
Cannulas that have some type of mechanical device to make them more (recipro-
cate or spin) are sold today. These are preferred by some surgeons for reduction of
SAT or for fat grafting [1]. This family of devices requires rather high cost of dis-
posable goods. The ergonomics of the device are poor, as it is somewhat large and
difficult to be precise with a long power handle and cannula assembly. With power-­

M. L. Jewell (*)
Oregon Health Science University and Private Practice, Portland, OR, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2020 3

O. Garcia Jr. (ed.), Ultrasound-Assisted Liposuction,
https://doi.org/10.1007/978-3-030-26875-6_1
4 M. L. Jewell

assisted lipoplasty, one is still performing SAL, but with a powered device. The
same limitations for SAL apply here along with the need to be ultraprecise with
technique when using a power tool. Personally, I never found this technology that
appealing, due to poor ergonomics and cost of disposables.
The concept of using laser energy to heat SAT has largely come and gone. Few
surgeons are using this technology currently. Laser-assisted lipoplasty (LAL) was
heavily marketed to noncore physicians as a magic way to “melt fat.” Unfortunately,
this became a perfect storm of physicians lacking basic lipoplasty skills, an under-
standing of tissue thermodynamics regarding safe laser dosimetry, and improper
selection of patients. The net outcome was tissue burns, contour irregularities, and
fat necrosis. The laser energy frequencies typically target the chromophores of
water and hemoglobin in tissues. With this comes heating of SAT to high tempera-
tures and obliteration of blood supply. The net effect is inflammatory fat necrosis.
Burns were an all too common adverse event associated with LAL. While market-
ing campaigns for LAL had catchy names like “Smart Lipo,” there was little science
or outcome data that validated the benefit of tissue heating with laser energy [2, 3].
LAL has become obsolete.
Radiofrequency-assisted lipoplasty (RFAL) has been around for a while, but has
not achieved wide adoption. This is just another tissue heating technology that uses
monopolar radiofrequency energy from a probe that is passed back and forth in the
tissue. Initial reports on this device demonstrated very high tissue temperatures in
the excess of 60C [4]. Later-generation devices incorporated temperature monitor-
ing features designed to mitigate risk of skin and tissue necrosis. There have been
reports of this device being used on arms to tighten tissue and in the female breast
to produce tissue tightening via an “internal mastopexy.” The equipment for RFAL
does have a disposable cost and is challenging to use from an ergonomic perspective
because of the tissue probe and accompanying return electrode.
Water-assisted liposuction that uses high-pressure fluid to disrupt adipocytes
from the collagen matrix is a novel concept [5]. The major limitation here is the
costs of disposable goods.
Ultrasonic-associated lipoplasty (UAL) has been around for a long time. There
was a lot of interest in this technology in the late 1990s and subsequent disappoint-
ment with outcomes. The two major plastic surgery organizations in the USA under
the leadership of Franklin DiSpaltro organized the Ultrasonic-Assisted Liposuction
Task Force to help train plastic surgeons on how to operate second-generation UAL
devices (Lysonix, McGhan Medical, Santa Barbara, CA; Wells Johnson, Tucson
Arizona; and Mentor Contour Genesis, Mentor Corporation, Santa Barbara, CA).
The task force offered didactic and bioskills training on the use of these devices.
Before this time, there was not an educational pathway for plastic surgeons to
become familiar with UAL.
In looking back, my analysis of what went wrong with traditional UAL involved
several issues. First, the devices from that era were ultrasonic-powered cannulas
that were inefficient as tissue fragmenters and aspirators. Second, surgeons did not
have a process to safely use UAL devices or what was a safe amount of ultrasonic
energy to apply (dosimetry). Most of the reported complications from early-­
generation UAL devices related to too much ultrasound or tissue burns from end of
1 Ultrasonic-Assisted Liposuction: Introduction and Historic Perspectives 5

the cannula touching the undersurface of the dermis (“end hits”) [6]. In the late
1990s UAL fell out of favor with surgeons.
I became intrigued with UAL during this time as it seemed to have promise as a
technique to improve the quality of lipoplasty but felt that given the inefficiency of
the devices was a major problem. My introduction to the third-generation UAL
devices called the VASER was approximately 17 years ago. Through William
Cimino, PhD, my colleague, Peter Fodor, MD, and I were intrigued with a new
approach for UAL with this device that was designed to overcome technical and
functional limitations of the inefficient and dangerous UAL devices.
William Cimino, PhD, took a very analytical approach to UAL and why the first-
and second-generation devices were not capable of delivering quality, safe out-
comes. Surgical ultrasound-powered devices were nothing new, yet there were
several things lacking in how UAL was performed and fat aspirated. First, fate frag-
mentation has to be accomplished with the least amount of energy (ultrasound), as
excess ultrasound in tissues produces adverse events seen with second-generation
UAL (burns, end hits, prolonged swelling, and seroma) that are the result of excess
tissue heating. Second-generation UAL devices actually aspirated during fragmen-
tation, thus removing the protective wetting solution that would mitigate tissue tem-
perature elevation.
The VASER system was designed with small-diameter solid titanium probes
with side grooving (Fig. 1.1). These would efficiently fragment fat at approximately

Fig. 1.1 The VASER

system, designed with
small-diameter solid
titanium probes with side
grooving
6 M. L. Jewell

¼ of the energy that second-generation ultrasound-powered cannulas required [7].

The side grooving of the probe end dispersed the ultrasonic energy and reduced the
risk of end hit burns. The ultrasound energy was applied in a pulsed fashion,
enabling tissue fragmentation without excess heat. Continuous ultrasound was also
possible, per surgeon preference.
The VASER system had a very precise fluid infiltration pump that could deter-
mine precisely to the cc how much wetting solution was infiltrated. This was useful,
as the amount of ultrasonic energy applied with the VASER hand piece/probe was
linked to volume of wetting solution infused, typically 1 minute of fragmentation
time per 100 ml of infused wetting solution. This provided for efficient fragmenta-
tion of fat, minimal blood loss in the lipoaspirate, and avoidance of excess ultra-
sound (heat) in the tissues. The fluid infiltration system can be used for tumescent
anesthesia for excisional body contouring or breast procedures.
Efficiency and precision in lipoaspiration was also addressed with the VASER
system. For years, literally back to the onset of liposuction in the UA, most surgeons
were using tri-port (“Mercedes-style”) aspiration cannulas designed by Grams
Medical, Costa Mesa, California USA. It was not unusual to see cannulas still in
service that were over 20 years old. The problem with the traditional tri-port can-
nulas was inefficient aspiration due to a phenomena of “vacuum lock” where the
ability of the cannula to efficiently aspirate declined as viscosity of aspirated fluid
increased. This was overcome with a small air bleed into the vacuum line at the
handle of the cannula. Additionally, Cimino and Fodor determined that cannulas
with smaller side ports were more efficient for aspiration through exhaustive bench
testing [8]. All VASER cannulas are equipped with a vented handle and are called
“VENTX” cannulas. This technology is licensed to other SAL device manufactur-
ers (Fig. 1.2).
Precision in the measurement of lipoaspiration was addressed with a canister
system in the VASER device (Fig. 1.3). This was useful in helping the surgeon be
more precise in the amount of lipoaspirate and avoidance of side-to-side variations
in the same anatomic area, e.g., outer thighs. Precision in the determination of
amount of lipoaspirate also is a safety issue where surgeons want to avoid excessive
removal of fat in order to prevent contour defects or thinning.
I still recall in 1990 receiving my first VASER system that was intended to serve
in a pilot study of the device that Dr. Fodor, Souza Pinto, and myself had agreed to
perform. The system arrived without much instructions or directions for use. It was
up to the three investigators to validate the principles of fragmentation time based
on the amount of wetting solution infused and the utility of the vented cannula
handle and canister system for measurement of lipoaspirate.

Fig. 1.2 “VENTX” cannula

1 Ultrasonic-Assisted Liposuction: Introduction and Historic Perspectives 7

Fig. 1.3 Precision in the

measurement of
lipoaspiration was
addressed with a canister
system in the VASER
device

Much to our surprise, everything functioned perfectly. Fodor and Jewell utilized
pulsed ultrasound (“VASER mode”) and Souza Pinto used continuous ultrasound in
his body contouring surgery. When the data was collected from the cases in our pilot
study, we determined that there were none of the complications formerly reported
with second-generation UAL devices and patient satisfaction was excellent. Results
were published in The Aesthetic Journal and presented at ASAPS [6].
Subsequently, application of the VASER system has expanded into areas of 3D
liposculpture (Hoyos and Millard), autologous fat harvesting into sterile canisters, and
use in combination with excisional body contouring procedures (lipoabdominoplasty,
Jewell) [9–11]. Depending on the size of probe used, VASER liposuction can be per-
formed in conjunction with facial rejuvenation procedures. Credit must be given to
Garcia for studying blood loss with VASER and conventional liposuction [12]. He
8 M. L. Jewell

determined that in similar body locations, the blood loss was considerably less with
the VASER.
The VASER system is the surviving UAL system that is in service today. It is
versatile, cost-effective to use, and extremely durable. Advances in UAL technology
enable patients to achieve reproducible clinical outcomes with the highest degree of
patient satisfaction and lowest risk of adverse events attributable to the technology.
The combination of technology, precision, finesse, and safety along with surgeon
training/patient selection is the key to success with the VASER.

References

1. Del Vecchio D, Wall S Jr. Expansion vibration lipofilling: a new technique in large-volume fat
transplantation. Plast Reconstr Surg. 2018;141(5):639e–49e.
2. Sasaki GH. Quantification of human abdominal tissue tightening and contraction after compo-
nent treatments with 1064-nm/1320-nm laser-assisted lipolysis: clinical implications. Aesthet
Surg J. 2010;30(2):239–48.
3. Jewell ML. Commentary on quantification of human abdominal tissue tightening and con-
traction after component treatments with 1064-nm/1320-nm laser-assisted lipolysis: clinical
implications (author: Gordon H. Sasaki, MD, FACS). Aesthet Surg J. 2010;30(2):246–8.
4. Blugerman G, Schavelzon D, Paul MD. A safety and feasibility study of a novel radiofrequency-­
assisted liposuction technique. Plast Reconstr Surg. 2010;125(3):998–1006.
5. Sasaki GH. Preliminary report: water-assisted liposuction for body contouring and lipohar-
vesting: safety and efficacy in 41 consecutive patients. Aesthet Surg J. 2011;31(1):76–88.
6. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA. Clinical application of VASER–
assisted lipoplasty: a pilot clinical study. Aesthet Surg J. 2002;22:131–46.
7. Cimino WW. Ultrasonic surgery: power quantification and efficiency optimization. Aesthet
Surg J. 2001;21:233–41.
8. Peter B, Fodor MD, Cimino WW, Watson JP, Tahernia A. Suction-assisted lipoplasty: physics,
optimization, and clinical verification. Aesthet Surg J. 2005;25:234–46.
9. Hoyos AE, Millard JA. VASER-assisted high-definition liposculpture. Aesthet Surg J.
2007;27:594–604.
10. Jewell ML. Lipoabdominoplasty: advanced techniques and technologies. In: Aston SJ,
Steinbrech DS, Walden JL, editors. Aesthetic plastic surgery. Amsterdam, Netherlands:
Elsevier; 2010. p. 765–73, Chapter 63.
11. Schafer ME, Hicok KC, Mills DC, Cohen SR, Chao JJ. Acute adipocyte viability after third-­
generation ultrasound-assisted liposuction. Aesthet Surg J. 2013;33(5):698–704.
12. Garcia O Jr, Nathan N. Comparative analysis of blood loss in suction-assisted lipoplasty and
third-generation internal ultrasound-assisted lipoplasty. Aesthet Surg J. 2008;28:430–5.
Chapter 2
Basic Science of Ultrasound in Body
Contouring

Mark E. Schafer

Background

Ultrasonic energy has been used for years in a wide array of medical applications –
from dentistry to neurosurgery. The roots of ultrasound surgical devices can be
traced back to the mid-1950s, with the development of ultrasound tools for dentistry
[1]. It was found that ultrasonic vibration in the presence of sufficient fluid provided
a simple effective treatment of dental calculus. The system reduced operator fatigue
by eliminating the need for heavy scraping and improved the patient experience by
reducing pain and bleeding.
This pattern of using ultrasonic vibration energy to reduce operator effort, with
improved patient outcomes, has been repeated in a number of device designs since
that time. Examples come from dentistry, neurology, ophthalmology, orthopedics,
wound care, and nephrology [2]. Ultrasound aspiration devices have been used to
successfully remove a range soft tissues such as skin, muscle, pathologic tissues
(tumor), and fat. A key feature of ultrasound technology is that it can be “tissue
selective,” sparing connective tissues, nerves, and blood vessels. Further, ultrasound
devices are designed to minimize heating, in order to reduce pain for the patient or
damage to nearby tissues.
Progress has continued with the application of ultrasound technology specifi-
cally to body contouring, starting in the late 1980s and early 1990s. With
­first-­generation ultrasound technology, ultrasound energy was applied in a continu-
ous manner (to be explained further later in this chapter) via a 4–6 mm solid,
­blunt-­tipped rod (or “probe”). This broke up fat deposits under the skin prior to
removal under vacuum via a separate hollow cannula [3]. So-called second-generation
systems switched to 5 mm hollow cannulae which permitted simultaneous fat

M. E. Schafer (*)
Sonic Tech, Inc., Lower Gwynedd, PA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2020 9

O. Garcia Jr. (ed.), Ultrasound-Assisted Liposuction,
https://doi.org/10.1007/978-3-030-26875-6_2
10 M. E. Schafer

f­ ragmentation and aspiration. However, the aspiration efficiency was limited by the
restricted 2 mm diameter inner lumen. Further, large access incision sizes of up to
1 cm were required to permit the use of relatively large instruments and skin protec-
tors. There were a number of reports of poor clinical outcomes and surgical compli-
cations with these first- and second-generation devices, which limited their
acceptance [4, 5].
In response to the shortcomings of traditional liposuction and prior energy-based
technologies, researchers began developing a third generation of ultrasound-assisted
liposuction system, called VASER (Vibration Amplification of Sound Energy at
Resonance), in the late 1990s. The VASER system was designed to advance liposuc-
tion procedures by improving safety and efficiency; reducing physician fatigue;
minimizing postoperative patient bruising, bleeding, and pain; and allowing for
faster recovery [6].
This chapter will describe the basic science of ultrasound in body contouring,
and specifically VASER technology, as well as a detailed explanation of the device
design and mechanism of action.

Basic Ultrasound Terminology

A form of mechanical energy, sound is a vibration or pressure wave that travels

through media. Sound travels in waves of higher and lower pressure. The high-­
pressure (compression) and low-pressure (rarefraction) regions alternate as the
wave travels. Compression causes particles to be pushed closer together, while rar-
efraction pulls the particles away from one another. This causes the individual par-
ticles to vibrate back and forth in place. The amplitude of the wave equals the
difference between the maximum values of compression and rarefraction (Fig. 2.1).

One full cycle

compression
Increasing

Peak
Amplitude

Trough
rarefaction
Increasing

Period=1/Frequency

Fig. 2.1 Illustration of relationship between compressional and rarefactional wave components,
including cycle period and frequency
2 Basic Science of Ultrasound in Body Contouring 11

The highest compression point is called the peak, while the lowest rarefaction point
is called the trough.
Sound waves are characterized by their frequency: the number of times the pres-
sure oscillates back and forth per second. Frequency is measured in Hertz (Hz),
which is cycles per second. Ultrasound waves vibrate at frequencies greater than
what can be detected by human hearing, which is about 18 kilohertz (18,000 Hertz)
and higher. The period is the time required to complete one cycle. The period is the
inverse of the frequency (cf Fig. 2.1).
Sound travels at a speed that is dependent upon the density and stiffness of the
media it is traveling through. For most soft tissues, this speed is about 1.5 mm per
microsecond. As the wave travels through a material, the wavelength is the distance
corresponding to one cycle of the wave. Thus the wavelength varies directly with
the speed of sound and inversely with the frequency. The higher the frequency, the
shorter the wavelength and the closer the spacing of the peaks and troughs.
Other key concepts in ultrasonics are “continuous” and “pulsed” energy.
Continuous, as the name implies, means that the ultrasound energy is on continu-
ously, without interruption, as long as the foot pedal (or other control) is depressed.
With pulsed (also labeled VASER mode), the ultrasound energy is rapidly switched
on and off during operation (multiple times per second). The advantage of the
pulsed setting is a lower overall average energy delivery and, thus, lower overall
potential to create heat (see next section). It also reduces the heat generated within
the ultrasonic motor inside the handpiece, which can affect operation and probe
longevity.

System Components and Operational Characteristics

Components The key components of the ultrasonic surgical system are a generator
or amplifier of electrical energy at a specific frequency, an ultrasonic motor which
converts electrical energy into mechanical motion (comprising a piezoelectric trans-
ducer and back and front masses), a coupler or horn (mechanical wave amplifier)
which conveys or amplifies the mechanical motion, and a probe which conducts the
mechanical motion to the tissue (Fig. 2.2). There are, naturally, other components,
such as a control mechanism (foot pedal, hand switch, knobs, user interface), a
handpiece of some sort for the operator to grasp and manipulate the device, and a
power supply.
As the electrical energy is applied, the handpiece transducer expands and contracts
to create longitudinal compression waves in the probe. As the probe tip moves for-
ward, it compresses the surrounding region. As the probe tip moves backward, rar-
efraction occurs. The forward and backward motion of the probe tip creates a
spherically expanding wave of ultrasound energy, as shown in Fig. 2.3, with alter-
nating compressional and rarefactional regions continually traveling outward in all
directions (note that Fig. 2.3 is color coded to match Fig. 2.1). The tip excursion is
12 M. E. Schafer

Fig. 2.2 Basic components of an ultrasound surgical system

Fig. 2.3 Illustration of the

spherical sound waves
emanating from the probe
tip. Colors representing
compression and
rarefaction match those in
Fig. 2.1

typically about 75 microns and the amplitude of the acoustic field is directly related
to this excursion. In other words, the greater the probe tip excursion, the greater the
amplitude of the acoustic field. The tip excursion is controlled by the front panel
setting.
Resonance A fundamental requirement of an ultrasonic surgical instrument is that
it operate at or near a mechanical resonance, just as a bell will ring at a specific
frequency when struck. Resonance enables the device to have maximum possible
2 Basic Science of Ultrasound in Body Contouring 13

excursion at the tip while requiring the minimum drive energy from the generator.
Thus the entire structure is designed to maximize the desired resonant mode while
minimizing the effects of any unwanted resonances. This is why handpieces and
systems are “tuned” to operate at a specific frequency.

Standing Waves When the compressional waves travel down the probe, they are
reflected back at the tip. The reflection pattern between the two waves produces a
“standing wave” that causes specific regions of the probe to have nearly no motion
(nodes) and other regions to have the highest motion (antinodes). The locations of
minimum vibration excursion are also the locations of maximum stress, which are
often the locations of mechanical failure due to metal fatigue. The tip is always an
antinode and has the highest level of longitudinal (forward and backward) vibration.
Since the tip is the main point of interaction with tissue, it is beneficial that it has the
most motion.
The nodes and antinodes will shift in position as a function of sound speed in the
probe material (a titanium alloy), and sound speed is temperature dependent. Thus
the operational characteristics of the system may change as the device is used,
which is why sometimes handpieces will stop operating after running for an
extended period of time. If a handpiece becomes sufficiently warm, the resonance
characteristic and node/antinode configuration can shift to the point that the ampli-
fier/generator can no longer match the required frequency.
Frictional Heating The nodes and antinodes alternate along the probe shaft at
intervals of one half wavelength. At an antinode location, the surface of the probe
shaft is moving quite rapidly (equivalent to over 12 miles per hour) and thus there is
the potential for frictional heating of anything that comes in contact with the probe
shaft in those regions. This is the reason that skin protectors should be used and that
the area around the skin entry point be kept moist and protected with wet towels.
Frictional heating effects along the probe shaft are another reason that pulsed mode
operation is typically preferred over continuous mode operation.

Mechanisms of Action

One of the most powerful aspects of ultrasound technology is that it can produce a
wide range of clinical effects depending upon the choice of frequency, amplitude,
mode of vibration, and probe design. The various mechanisms of action can be
combined and/or tailored to meet specific clinical requirements. In the case of body
contouring, cavitation and acoustic streaming are combined to create a safe, effec-
tive means of extracting adipocytes, with minimal effect on the surrounding tissue
matrix.
Cavitation Cavitation is the term given to the action of gas bubbles in fluids; the
science of cavitation is the subject of entire books (e.g., [7]). Cavitation is necessary
14 M. E. Schafer

for efficient operation, and thus it is important to understand the different types of
cavitation and how ultrasound can create, sustain, and destroy bubbles.

Cavitation Nuclei and Rectified Diffusion At atmospheric pressure and tempera-

ture, water will contain billions of microscopic air bubbles or cavitation nuclei.
These are unavoidable, because air will diffuse into water until it reaches an equi-
librium saturation point. Thus the tumescent solutions used during body contouring
procedures contain dissolved gas (air) and cavitation nuclei. These microbubbles
are in equilibrium with the gasses dissolved in the fluid, with gas continually diffus-
ing into and out of the bubbles in equal amounts.
The sound waves emanating from the tip of the probe produce a push/pull force
on the dispersed gas microbubbles. As the pressure wave pulls on the microbubbles,
they expand, increasing their surface area and allowing additional gas dissolved in
the fluid to enter by diffusion. The pressure wave next pushes on the bubble, com-
pressing it and causing some of the gas in the bubble to diffuse back out. Since the
bubble is smaller when compressed by the pressure wave, less gas diffuses out dur-
ing compression than diffuses in when the bubble is under tension. Thus, with the
passage of every ultrasound wave, there is an overall net increase in the volume of
the gas bubble. This process is called rectified diffusion [8–10]. Figure 2.4 illus-
trates this process.
The bubbles rapidly expand from 5 to 10 microns to their resonant size, which is
determined by the physical properties of the fluid (surface tension, viscosity, and

Fig. 2.4 Illustration of rectified diffusion. Under the influence of the ultrasound wave, bubbles
grow until they reach resonant size, followed by collapse. (Illustration by Travis Vermilye)
2 Basic Science of Ultrasound in Body Contouring 15

density) and the frequency of the applied ultrasound. For a frequency of 36.6 kHz
(the operational frequency of the VASER system), the resonant bubble size is
approximately 180 microns. At resonance, the bubble expands and contracts vigor-
ously with each ultrasound pressure fluctuation. At this point, there are two possible
outcomes: either the bubble collapses violently or it breaks apart more gently. The
former situation is called transient or inertial cavitation, and the latter is called sta-
ble cavitation.
Transient Cavitation In this case, the bubble collapses down into a very small
volume, creating extremely high focal pressures and temperatures [11]. It is a very
localized phenomenon, just in the immediate region of the probe tip, and has rela-
tively minor effect on tissue. However, this is the mechanism by which the end of
the probe becomes eroded with use. Figure 2.5 illustrates the effect on the probe tip,
with evidence of pitting from transient cavitation bubble collapse.

Stable Cavitation The other fate of resonantly vibrating bubbles is that they simply
break apart more gently rather than collapsing violently. In this case, the bubble
fragments are then available to start the rectified diffusion process anew. One fea-
ture of stable cavitation is the large cyclic pulsations at resonance that cause large
shear forces in the region around the bubble. These shear forces can dislodge cells
from their tissue matrix, as will be discussed later in this chapter.
One of the most important things to understand about cavitation is that it is the
action of ultrasound on gas bodies, whether cavitation nuclei or bubbles. Since the
body’s cells contain no free gas, only fluid, ultrasound energy cannot cavitate the
cells themselves. Only the bubbles in the surrounding interstitial media can interact
with the ultrasound waves to create cavitation effects. Further, since adipocytes are
filled with higher viscosity fluids (lipids), they are particularly resistant to the action
of the ultrasonic waves and to the possibility of cavitating.

a b c

Fig. 2.5 Probe tips. (a) New probe, (b) probe with some pitting from transient cavitation bubble
collapse, (c) probe with extensive cavitation damage
16 M. E. Schafer

Acoustic Radiation Force and Streaming A propagating ultrasonic wave creates a

net force on the medium through which it travels, called the acoustic radiation force
[12, 13]. This force acting on fluids can produce a flow that is often called acoustic
streaming. Additionally, the immediate volume around the end of the probe is sub-
ject to high shear forces as the probe tip moves back and forth within a fluid. These
shear forces induce fluid flows [14], which, confusingly, have also been referred to
as acoustic streaming. Figure 2.6 illustrates the effect of these forces around a probe
tip. For this experiment, the tip was immersed in a small water chamber with trans-
parent walls, partially filled with water. When the probe was energized, the water
level in the chamber was forced up in the region where the probe entered the water.
The streaming forces near the probe are shown by the arrows.

Acoustic Pressure and Power As described earlier, ultrasound energy is generated

by the vibrational movement right at the tip. The acoustic pressure level from the
probe can be expressed as a function of frequency, excursion, and cross-sectional
area of the probe tip [15, 16]. Thus increasing the probe excursion (by increasing the
output setting on the generator) increases the pressure output and therefore the vari-
ous effects described above. Another way to change the pressure is to change the
cross-sectional area, either by choosing a probe with a different diameter or one that
has more “rings” (See Fig. 2.7). The rings create additional vibrating surface area
and thus more acoustic output and more streaming and cavitation. However, the
rings do not impart any particular directionality to the acoustic energy pattern from
the tip: the general pattern of wave energy from the tip matches Fig. 2.3 irrespective
of the number of rings.

Fig. 2.6 Photograph

showing acoustic
streaming effects. Dotted
line is water level with no
ultrasound energy. Upon
activation, acoustic
streaming near the probe
tip (circular arrows)
produces a net flow of
water toward the surface
(straight arrows), raising
the water level
2 Basic Science of Ultrasound in Body Contouring 17

Fig. 2.7 Photograph of various VASER probe tips, showing a range of diameters and number of
rings. The diameter and number of rings affect the total acoustic energy delivered by the probe

Fat section Fat pearl Fat lobule Fat cells (adipocytes)

Fig. 2.8 Illustration of organization of fat within the body. (Illustration by Travis Vermilye)

Interaction of Ultrasound with Fat

Individual fat cells are contained within larger groups of cells that comprise fatty
tissue. Fat cells are part of fat lobules, which are part of fat pearls, which are con-
tained within fat sections, which are within fat compartments (Fig. 2.8). Since fat
cells have the ability to change dramatically in size (from 20 to over 200 microns in
diameter as a person gains weight), they are bound together relatively loosely com-
pared to muscle, fascia, nerves, and blood vessel cells. Figure 2.9 is an illustration
of fat cells in the vicinity of a small vessel. Note that while the fat cells are loosely
18 M. E. Schafer

Fig. 2.9 Illustration of fat

before infusion of
tumescent fluid, including
nearby blood vessel.
(Illustration by Travis
Vermilye)

Fig. 2.10 Illustration of

fat after infusion of
tumescent fluid. Note that
the fluid has infiltrated
throughout the fat region,
including between the fat
cells. (Illustration by
Travis Vermilye)

bound, the cells of the blood vessel wall have tight junctions (thus preventing
­leakage of blood into the interstitial medium).
During body contouring, tumescent fluid is infused throughout the targeted fatty
tissue area. As noted earlier, the tumescent fluid naturally contains small gas bub-
bles on the order of 5–10 microns. As the fluid is infused, the microbubbles become
dispersed throughout the tissue matrix. Due to the relatively loose packing of the
fatty tissue, the tumescent fluid surrounds the fat cells, allowing the gas bubbles to
infiltrate between individual cells. In contrast, the tight junctions between cells
within blood vessel walls and connective tissues prevent gas bubbles from inter-
spersing among and affecting these tissues (see Fig. 2.10).
When subjected to the ultrasound field from the probe tip, the bubbles grow by
rectified diffusion to their resonant size, allowing the bubbles to act as wedges
between the fat cells, dislodging the cells from the adipose matrix (Fig. 2.11). Once
the bubbles reach their resonant size, they collapse, pulling on and further loosening
the fat tissue matrix. The progression then starts over again.
2 Basic Science of Ultrasound in Body Contouring 19

Fig. 2.11 Illustration of

bubbles activated by
ultrasound energy,
expanding in the regions
between the fat cells, thus
loosening them from the
tissue matrix. Because the
bubbles cannot infiltrate
between the tight cellular
junctions of the blood
vessel, it is not affected.
(Illustration by Travis
Vermilye)

Fig. 2.12 Illustration of

cavitation and acoustic
streaming in the region of
the probe tip. Acoustic
streaming acts to dislodge
and create a suspension of
fat cells in the tumescent
fluid, just as it did in
Fig. 2.6. (Illustration by
Travis Vermilye)

As the fat cells are displaced, they are mixed with the tumescent fluid by through
acoustic streaming, resulting in a complete suspension of the fat cells, which are
subsequently aspirated (Fig. 2.12).
Since adipose cells contain no gas, ultrasound energy does not cavitate adipose
cells. Analysis of fat aspirated after ultrasound-assisted lipoaspiration (UAL) con-
firms that the technique does not cause widespread destruction of fat cells and
release of lipids [17]. Also, since the bubbles cannot intersperse between the cells of
blood vessels, nerves, and other similar tissues, the bubble-mediated cavitation
action only acts to dislodge the adipose cells, leaving the other tissues unaffected.
This natural tissue selectivity of VASER technology helps reduce patient blood loss
during procedures and help maintain a healthy tissue environment post-surgery,
speeding healing and minimizing patient discomfort.
Since individual fat cells remain intact, fat collected during the procedure may be
harvested for autologous fat transfer [17, 18]. The strong acoustic streaming action
refines the aspirated fat down to small lipocyte packets comprised of 2–3 fat cells,
20 M. E. Schafer

which supports growth and vascularization upon reinjection. This is in contrast to

the fat aspirated during other liposuction procedures, which may be harvested in
large cell packets approximately 50 cells in diameter. These large cell clusters are
associated with high rates of cell disruption from shear forces during reinjection and
necrosis at the core after reimplantation due to inadequate blood supply. The VASER
system utilizes acoustic forces to safely dislodge fat cells while protecting sur-
rounding tissues, ultimately producing a clean, smooth aspirate with excellent cell
viability.

Summary

Based on decades of ever-expanding clinical utility, third-generation ultrasonic

liposuction systems for body contouring have evolved to be ideally suited to safe,
effective treatment. The VASER® system combines a relatively high frequency
(36.6 kHz), low excursion levels (below 75 microns), pulsed operation, and probe
rings (to increase the effective area) to optimize ultrasound delivery. It exploits spe-
cific ultrasonic phenomena, namely, stable cavitation and acoustic streaming, to
create a unique tool for the safe removal of fat from the surrounding tissue. It thus
provides several benefits, including tissue specificity, limited blood loss and patient
discomfort, smooth skin retraction, and preservation of fat cell viability for recon-
structive or cosmetic purposes [17, 18].

Acknowledgement Figures 2.4, 2.8, 2.9, 2.10, 2.11, and 2.12 Illustration by Travis Vermilye

References

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2. Schafer ME. Ultrasonic surgical devices and procedures. In: Gellego-Juarez J, Graff K, edi-
tors. Power ultrasonics, applications of high intensity ultrasound. Cambridge, UK: Woodhead
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3. Zocchi M. Clinical aspects of ultrasonic liposculpture. Perspect Plast Surg. 1993;7:153–74.
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