National report — Ultrasound-assisted lipoplasty (UAL), incorporating ultrasonic energy in liposuction, may seem like a one-hit surgical wonder.
It made a dramatic debut in the United States in 1997, but enthusiasm for it quickly waned.
The procedure, which seemed to pose too many unknowns, fell out of favor, with surgeons falling back on the traditional
suction-assisted lipoplasty (SAL).
However, Jorge A. Perez, M.D., finds that UAL is perhaps more misunderstood than it is dangerous, according to a recent study
he compiled with Dr. Joost P.B. van Tetering.
Results of the study, "Ultrasound-Assisted Lipoplasty: A Review of Over 350 Consecutive Cases Using a Two-Stage Technique,"
counter the previously set time limitations on ultrasonic usage that were meant to prevent burns. The study concluded that
there is no correlation between application time and burns to the skin, with the caveat that two rules be followed without
exception.
The two rules, formulated by Italian surgeon Dr. Michael Zocchi, stipulate that doctors should never apply ultrasonic energy
to dry tissues, and they should keep the cannula moving at all times.
When the cannula stops moving, complications arise; in fact, tissue damage can happen within seconds, according to the study.
While some surgeons claim that there is little or no difference between the results of UAL and SAL, Dr. Perez disagrees.
"The problem with SAL is that the suction doesn't discriminate between the good tissue and the bad tissue. It suctions out
everything. And within that subcutaneous tissue, in addition to the fat, are things like blood vessels and nerves and fibrous
tissue — things that you want to protect and preserve," he says.
Methodology Just as with SAL, an entryway is made in the skin to introduce the cannula. But instead of suctioning out the tissue with
the suction energy, the tip of the cannula gives off a sound wave that is specific in frequency to fat cells, which then turns
the fat cells into an oil. The oil is then removed with a gentle suction.
But more specifically, Dr. Perez and Dr. van Tetering modified their process from a three-stage technique, which begins by
infiltrating the body part with a tumescent fluid, then applying the energy, and finally, using traditional liposuction to
suction out the fat. Their technique skips the traditional liposuction stage, or what's called "mopping up." They basically
inject the tumescent fluid, then apply the energy and the suction simultaneously. As for time, Perez says that if, for example,
an abdomen requires 45 minutes of UAL, doctors should spend 45 minutes on it, keeping the two main principles in mind.
On a clinical level, says Dr. Perez, that translates into less bruising, less pain and smoother results — not to mention a
faster recovery. He says it's not unusual for his patients to take nothing stronger than Tylenol for pain.
While some claim that there is little or no difference between the results of ultrasound-assisted lipoplasty and traditional
suction-assisted lipoplasty, Jorge A. Perez, M.D., disagrees.
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"I did UAL on a gentleman recently," Dr. Perez says. "He owns and operates a very busy gourmet market; this guy works 80-hour
weeks. He had liposuction on a Friday, and was back at the market on Saturday, running the store. That's the kind of recovery
we get with this procedure."
Warnings Dr. Perez does warn against three practices that will cause burns, or thermal ischemic injuries. The warm cannula can cause
injury at the entry portal; Drs. Perez and van Teetering recommend inserting a plastic wound protector into the access incision.
Likewise, a "stripe" burn can occur from the "cannula shaft rubbing against the skin proximal to the entry portal," and the
authors suggest protecting the area with a moist towel.
The third type of injury, resulting from a punctate area, or an "end hit," could be a "subdermal devascularization or thermal
event." It's the rarest injury, in the course of Drs. Perez and van Tetering's study, and the most severe. To prevent this
from happening, the surgeons emphasize the importance of carefully applying the energy in the superficial plane without tenting
up the skin. Additionally, theycaution against applying suction while the cannula is in the immediate subdermal plane.
Dr. Perez further addresses the time constraints placed on UAL, and how they may have led surgeons to be dissatisfied with
the results.
"The problem is, if you come along and you do five minutes of UAL, and then you finish the rest of the surgery with regular,
traditional liposuction, you would expect to see a result that's typical of regular, traditional liposuction. And that's what
they found. So then those same people said, 'Well, the results are no different from what I get from traditional liposuction.'
"
As the enthusiasm for UAL cooled in the United States, the manufacturers of UAL equipment adjusted for the fall in demand.
But companies such as Mentor are working to improve the existing devices and develop the next generation of UAL equipment.
One significant difference between operating UAL and SAL equipment is that the titanium cannula can't be bent, because curving
the ultrasonic device weakens its effectiveness. In order to remedy this, the cannula can be maneuvered in a crisscrossing
pattern. It's one of the several differences a surgeon would encounter in UAL training.
Though Dr. Perez feels that there's indeed a learning curve, as with any new procedure, he says, "I personally think to get
consistent, safe results with ultrasonic is comparable to what it would be with a surgeon learning traditional liposuction,
as long as they adhere to the two basic rules — to keep the tissue wet and to keep the cannula moving. To obtain better results,
there's always a bit of a learning curve. Every surgeon's a little different, but you have to do more than a handful of cases
to really develop a finesse with it."
Dr. Perez says that UAL has replaced traditional liposuction in his office and that he and his patients continue to be very
happy with the results.
For more information: Perez J, van Tetering JPB. Ultrasound-assisted Lipoplasty: A Review of Over 350 Consecutive Cases Using a Two-Stage Technique.
Aesthetic Plast Surg. 2003;27:68-76.
