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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

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
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
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