Abstract
Liposculpture procedures have gained popularity over the last 2 decades with the evolution of surgeons’ skills and technological advancement. According to the 2018 The Aesthetic Society report, liposuction is the second-most popular aesthetic procedure in the United States.
The authors aimed to demonstrate that a spectrum of liposculpture definitions can be achieved utilizing power-assisted liposuction (PAL). Also, the authors sought to describe the satisfaction and complication rates in mild-, moderate-, and high-definition groups utilizing the PAL technology.
The authors designed a single-center retrospective study, including male patients who underwent PAL liposculpture of the chest, abdomen, back, and arms. Inclusion criteria were male patients >18 years of age and body mass index <30 kg/m2. Measured outcomes included extent of definition, complication rates, and levels of satisfaction.
Fifty male patients were included in this study between January 2018 and November 2019. The average age was 37.34 years (range = 25-56 years). The average body mass index was 26.4 kg/m2 (range = 24-30 years). A total of 54.3% of patients opted for high definition (HD), 36.4% for moderate definition, and 9.2% for mild definition. There were no major complications. The HD subgroup registered the highest incidence of minor complications (21%). Patient satisfaction levels were high in all 3 subgroups, with the highest scores in the HD subgroup (9.3/10).
A spectrum of definitions can be safely achieved utilizing the PAL technology, with high patient satisfaction in mild-, moderate-, and high-definition liposculpture subgroups and low complication rates.
Body contouring procedures have gained popularity over the last 2 decades. This is directly attributed to the evolution of surgeons’ skills and advancements in the applicable technologies. According to the 2018 The Aesthetic Society report, liposuction ranks as the second-most popular aesthetic procedure in the United States with 289,261 registered cases, a 24% increase from 2014.1
Liposuction, as we know it today, is the result of 100 years of technical and technological evolutions. In the 1920s, Charles Dujarrier utilized a uterine curette to remove fat from a ballerina’s knees.2 His lack of success and consequent complications made the procedure unpopular. In the late 1970s, French surgeon Yves-Gerard Illouz described the advantages of blunt-tip cannulas and subcutaneous infiltration, becoming the father of modern liposuction.3 To replace traditional liposuction and improve surgical outcomes, a wide range of technologies has been developed and introduced to the market. These technologies include ultrasound, light amplification by stimulated emission of radiation (LASER), radiofrequency, and mechanical energy devices.4
In 1998, power-assisted liposuction (PAL) technology was approved by the US Food and Drug Administration.5 This reciprocating mechanical device recreates the forward and reverse motion of the operator’s arm with the cannula tip. Along with negative suction pressure, the low amplitude (3 mm) reciprocating motion allows the surgeon to precisely sculpt the body fat at 2000 to 4000 cycles per minute.6 Under magnification, it has been shown that the PAL technology is less traumatic to the structures around the treated fat compared with suction-assisted lipectomy.7 In 1993, Mentz et al described the concept of abdominal etching through precise liposuction of the superficial fat.8 In 2007, Hoyos et al described the concept of high-definition liposculpture employing the vibration amplification of sound energy at resonance technology, which has gained international popularity among surgeons and patients alike.9 Our group has recently published the effectiveness and advantages of the PAL-based techniques for high-definition liposculpture, demonstrating its safety and ability to deliver reproducible natural-looking results with high patient satisfaction rates, low risk of complications, and a relatively short and tolerable recovery process.6,10
Through differential sculpting of the superficial fat layer, plastic surgeons are able to control the extent of body definition. This article describes our experience in achieving different levels of definition in patients who requested full-torso and arm liposculpture utilizing the PAL technology. We also introduce the concepts of mild definition (MiD) and moderate definition (MoD), creating what we called “the spectrum of definitions.”
Besides demonstrating that a spectrum of liposculpture definition levels can be technically achieved with PAL, we report satisfaction and complication rates in all 3 patient subgroups.
METHODS
This study was designed as a single-center retrospective case series. We described our intraoperative techniques to differentially sculpt the superficial fat layer to achieve the 3 levels of definitions. We also reported patients’ satisfaction and complication rates.
Patients
All patients were evaluated for candidacy for the procedure and inclusion in the study by the first author (A.N.S.). Inclusion criteria were the following: male patients, older than 18 years of age, with a body mass index (BMI) <30 kg/m2. Exclusion criteria included abdominal muscle diastasis assessed by palpation, history of massive weight loss or bariatric surgery, significant medical/psychological comorbidities, contraindications to general anesthesia, and any significant comorbidity (eg, uncontrolled diabetes, uncontrolled hypertension) with an American Society of Anesthesiologists score >2. On physical exam, skin tonicity and elasticity, and presence and location of scars from previous surgeries were taken into consideration. Subcutaneous and intra-abdominal fat were differentiated with the pinch test. Written informed consent was given by all patients.
From January 2018 to November 2019, 50 male patients who had PAL liposculpture of the chest, abdomen, back, and arms performed by the first author were included in this retrospective analysis. This study conforms to the guiding principles of the Declaration of Helsinki.
Collected demographic and clinical data included patients’ age and BMI. Intraoperative data comprised mean operative time, mean lipoaspirate volume, and extent of definition. Postoperative data encompassed follow-up time, major (requiring surgery under general anesthesia) and minor (solved without or with minor intervention in the clinic) complications, and patient satisfaction scores (questionnaires were not anonymous, with scores ranging from 1 to 10, with 1 being extremely bad and 10 being outstanding), which were recorded during patients’ 6-month postoperative follow-up visit and distributed by our team members (Appendix).
All patients were categorized preoperatively employing our proposed classification system of MiD, MoD, and HD groups. This was achieved by showing patients multiple before-and-after-surgery photographs of similar cases performed by the same surgeon where different levels of definition were achieved. The extent of definition was decided through consensus between the patient and the surgeon, taking into consideration the patient’s body habitus, anatomy, desire, and surgeon’s recommendation. Patients were informed of the risks, including possible deformities in the short and long postoperative course, benefits, and alternatives to the planned procedure. They were also instructed to maintain their weight, healthy diet, and lifestyle after surgery to continue improving their results.
The Spectrum of Definitions
The PAL technology, through its low-amplitude reciprocation, allows the surgeon to perform lipocontouring for the deep fat layers and superficial fat liposculpting (SFLS) to achieve different grades of anatomic definition.10
All 3 grades of the spectrum of definitions can be achieved intraoperatively by controlling the amount and location of the fat preserved in the superficial layer, the sharpness of the edges, and the transition points (Figure 1). The underlying muscle volume is a significant feature that needs to be taken into consideration, because that alone can cause a differential fat depth.
Spectrum of definition: superficial fat liposculpting degrees. Three levels of definitions: mild, with minimal difference in projection between treated and untreated superficial fat and least edgy transition; moderate, with moderate difference in projection between treated and untreated superficial fat and moderately edgy transition; and high, with significant difference in projection between treated and untreated superficial fat and sharp edgy transition.
We propose the following classification of the 3 levels of definition based on the extent of SFLS and the difference in skin height and projection between the treated and untreated areas of the superficial fat layer:
MiD: 3-5 mm of fat;
MoD: 5-7 mm of fat;
HD: 7-9 mm of fat.
Surgical Technique
Marking was completed preoperatively while patients were in standing position. This was guided at all times by patients’ underlying bony and muscular anatomy. The first area to be marked was the pectoral region following the anatomy of the pectoralis muscles. The upper pole of the chest volume was evaluated to establish the need for fat grafting. The abdominal anatomy was palpated and marked; it must be taken into consideration that the rectus abdominis bellies are not always parallelly disposed and symmetric. Then the iliac crests and ligaments were marked. The groove between the deltoid and the biceps anteriorly and deltoid and triceps posteriorly was also marked. In the lower back, the lateral border of the thoracolumbar fascia, the inferior border of the latissimus dorsi, and the superior border of the gluteus maximus were marked.
The intraoperative details were previously published in Aesthetic Surgery Journal.6 In brief, the process began with the patient in a prone position. The first areas to be treated were the upper and lower back, including the gluteal region and the posterior arms. Then the patient was turned to a supine position, where anterior arms, chest, medial, and lateral abdomen were treated. Finally, fat transfer to the chest was performed whenever indicated.
The stepwise protocol we employed for the PAL liposuction followed a similar structure to what was previously described by Wall et al.11 However, we propose a slight modification to what has been previously described in the literature: the utilization of the reciprocating power of the technology, without suction, to enhance the tumescent solution dispersion as a second and separate step from the infiltration.
Step 1: Infiltration
During the infiltration process, we utilize the super-wet technique. The infiltration solution (1000 mL of 0.9% NaCl, 20 mL of 1% lidocaine, 1 mL [1:1000] epinephrine) is injected through 5-mm hidden incisions in the natural body folds of the axilla, nipple-areola complex, umbilicus, lower abdomen, and supra-gluteal areas. To create a “six-pack,” it is not necessary to add further incisions on the abdominal wall.
To maximize the epinephrine and lidocaine effects of the wetting solution, we waited 15 minutes before proceeding to the next step.
Step 2: Dispersion
This step consists of the utilization of PAL’s vibratory energy without suction power. The goal is to maximize the interaction between the tumescent fluid components and the fat tissue after these areas have been partially exposed to tumescence in the infiltration step. This step should enhance the effect of epinephrine and lidocaine in the treated zone and decrease blood levels in the lipoaspirate and improve pain control, respectively.
Step 3: Aspiration
Liposuction was performed utilizing PAL technology without any other energy device. Both superficial and deep fat harvesting were conducted utilizing 5-mm (straight and bent) PAL HD cannulas (Microaire, Inc., Charlottesville, VA). The architecture of the PAL-HD cannula allows less aggressive treatment of the superficial subcutaneous fat and more aggressive (basket cannula characteristics) aspiration of the deeper fat. Also, with the utilization of both straight and bent cannulas, we avoid making additional access incisions on the abdominal wall (Figure 2).
High-definition (HD)–power-assisted liposuction (PAL) cannulas, both straight and curved. The superficial surface of the cannula has small holes that make it less aggressive on more superficial fat. The deeper side has “basket properties,” which make it more aggressive and efficient in fat extraction from the deeper layer (Microaire, Inc., Charlottesville, VA).
The SFLS consists of the detailed sculpting of the superficial fat layer to enhance the underlying musculoskeletal structures. Fat should always be aspirated following the preoperative markings as guidelines throughout the whole surgery. It is imperative to avoid “torquing movements” while the cannula is intracorporeal to preserve the integrity of perforator vessels and reduce ecchymosis and potential skin ischemia.12
It is in this step that the desired level of definition is achieved. It depends on the sharpness of the edges that are created and the amount of fat preserved in the superficial fat layer. This can be controlled with the extent of liposuction followed by the degree of fat equalization. Measurement of the differential fat thickness is made as soon as the demarcation is created, before onset of swelling, utilizing a ruler. As the surgeon gains experience utilizing this technique, visual cues will replace the actual measurements (Figure 1).
Fat is collected and processed utilizing the Lipofilter System (Microaire, Inc.) in case fat is needed for transfer.
Step 4: Fat Equalization
This step consists of utilizing the reciprocating movement of the PAL technology without suction. This helps treat irregularities and correct any step-offs that could have been created during the aspiration phase.11
No drains were employed. Wounds were closed with absorbable sutures, and dressings were applied. We utilized EpiFoam (Biodermis, Inc, Henderson, NV) strips over the superficially sculpted regions in both anterior and posterior areas. Patients were placed in compression garments (Marena, Lawrenceville, GA), then extubated in the operating room.
Postoperative Care
All the patients were admitted to the hospital for overnight observation and discharged on postoperative day 1. Patients had scheduled postoperative visits on postoperative days 3, 7, and 21; 6 weeks; 3 and 6 months; and 1 year to evaluate the results. The rehabilitation protocol included 2 sessions of lymphatic draining massage starting the second postoperative week, followed by additional sessions as needed. Compression garments were utilized for 3 weeks. There were no revisional surgeries. Minor complications were treated in the clinic non-surgically. Patient satisfaction scores were recorded 6 months after the surgery.
Statistical Analysis
Descriptive analysis was performed utilizing mean, standard deviation, and data range. Satisfaction scores, BMI, and lipo-aspirate volumes were compared in the 3 groups postoperative an ANOVA test. Employing a Bonferroni correction, statistical significance was defined as P < 0.05.
Statistical analysis was performed utilizing the SPSS statistical analysis software 25.0 (SPSS, Inc., an IBM Company, Chicago, IL).
RESULTS
Patient Population
Fifty male patients who underwent PAL-liposculpture were included in this series. The average age of the patients was 37.3 ± 7.8 years (range = 25-56 years). The average BMI was 26.4 ± 1.2 kg/m2 (range = 24-30 kg/m2) (Table 1).
Patient Demographics (n = 50)
| Characteristic | Mean ± SD | Range |
|---|---|---|
| Age (y) | 37.34 ± 7.88 | 25-56 |
| BMI (kg/m2) | 26.44 ± 1.27 | 24-30 |
| Characteristic | Mean ± SD | Range |
|---|---|---|
| Age (y) | 37.34 ± 7.88 | 25-56 |
| BMI (kg/m2) | 26.44 ± 1.27 | 24-30 |
BMI, body mass index.
Patient Demographics (n = 50)
| Characteristic | Mean ± SD | Range |
|---|---|---|
| Age (y) | 37.34 ± 7.88 | 25-56 |
| BMI (kg/m2) | 26.44 ± 1.27 | 24-30 |
| Characteristic | Mean ± SD | Range |
|---|---|---|
| Age (y) | 37.34 ± 7.88 | 25-56 |
| BMI (kg/m2) | 26.44 ± 1.27 | 24-30 |
BMI, body mass index.
Surgical Outcomes
Regarding the extent of definition, 5 (9.2%) patients chose MiD, 17 patients (36.6) MoD, and 28 (54.3%) patients opted for HD (Figures 3-6).
Distribution of extent of definition: percentages of patients who opted for mild, moderate, and high definitions.
Mild-definition liposculpture in this 32-year-old male patient with a body mass index of 28 kg/m2. (A) Preoperative image showing an anterior view. (B) Thirteen-month postoperative image; mild-definition liposculpture of the arms, abdomen, back, and chest with fat transfer to the chest.
Moderate-definition liposculpture in this 32-year-old male patient with a body mass index of 26.3 kg/m2. (A) Preoperative image showing an anterior view. (B) Twelve-month postoperative image after moderate-definition liposculpture of the arms, abdomen, back, and chest with fat transfer to the chest.
High-definition liposculpture in this 37-year-old male patient with a body mass index of 23.7 kg/m2. (A) Preoperative image showing an anterior view. (B) Twelve-month postoperative image after high-definition liposculpture of the arms, abdomen, back, and chest with fat transfer to the chest.
The average operative time was 188.30 ± 16.18 minutes (range = 155-230 minutes). The average lipoaspirate volume from was 5021 ± 1062 mL (range = 2700-7800 mL) (Table 2). The average follow-up period was 13 months (range = 6-24 months) (Table 3).
Intraoperative Variables
| Variable | Mean ± SD | Range |
|---|---|---|
| Surgical time (min) | 188.30 ± 16.18 | 155-230 |
| Lipoaspiration volume (mL) | 5021 ± 1062 | 2700-7800 |
| Variable | Mean ± SD | Range |
|---|---|---|
| Surgical time (min) | 188.30 ± 16.18 | 155-230 |
| Lipoaspiration volume (mL) | 5021 ± 1062 | 2700-7800 |
Intraoperative Variables
| Variable | Mean ± SD | Range |
|---|---|---|
| Surgical time (min) | 188.30 ± 16.18 | 155-230 |
| Lipoaspiration volume (mL) | 5021 ± 1062 | 2700-7800 |
| Variable | Mean ± SD | Range |
|---|---|---|
| Surgical time (min) | 188.30 ± 16.18 | 155-230 |
| Lipoaspiration volume (mL) | 5021 ± 1062 | 2700-7800 |
Postoperative Variables
| Variable | Mean ± SD | Range |
|---|---|---|
| Follow-up time (mo) | 13.06 ± 16.18 | 6-24 |
| Admission time (h) | <24 | <24 |
| Variable | Mean ± SD | Range |
|---|---|---|
| Follow-up time (mo) | 13.06 ± 16.18 | 6-24 |
| Admission time (h) | <24 | <24 |
Postoperative Variables
| Variable | Mean ± SD | Range |
|---|---|---|
| Follow-up time (mo) | 13.06 ± 16.18 | 6-24 |
| Admission time (h) | <24 | <24 |
| Variable | Mean ± SD | Range |
|---|---|---|
| Follow-up time (mo) | 13.06 ± 16.18 | 6-24 |
| Admission time (h) | <24 | <24 |
Patients included in this study had no significant complications and no revisional surgeries. However, 16% of the patients had minor complications (14% had fluid collections in different areas, most commonly in the suprapubic region). Although we did not encounter complications in the MiD subgroup, they were seen in 11.7% of the MoD subgroup. The highest incidence of minor complications was observed in the HD subgroup (21.4%) (Table 4). All fluid collections were drained in the clinic under local anesthesia utilizing 14-Gauge needles and 50-mL syringes. Most fluid collections recurred and required second drainage. One patient had persistent fibrosis in the linea alba and was treated at 3 months postoperatively with 1 session of transcutaneous ultrasound and 2 sessions of manual massage. All minor complications were treated non-surgically in our clinic (Figure 7).
Distribution of Complications in Each Group
| Extent of definition | ||||
|---|---|---|---|---|
| Mild (n = 5) | Moderate (n = 17) | High (n = 28) | Total (n = 50) | |
| Complication | ||||
| Fluid collection (suprapubic) | 0 | 0 | 4 (14.2%) | 4 (8%) |
| Fluid collection (interpectoral triangle) | 0 | 0 | 1 (3.5%) | 1 (2%) |
| Fluid collection (lateral abdomen) | 0 | 0 | 1 (3.5%) | 1 (2%) |
| Fluid collection (lower back) | 0 | 1 (5.8%) | 0 | 1 (2%) |
| Fibrosis (linea alba) | 0 | 1 (5.8%) | 0 | 1 (2%) |
| Total | 0 | 2 (11.7%) | 6 (21.4%) | 8 (16%) |
| Extent of definition | ||||
|---|---|---|---|---|
| Mild (n = 5) | Moderate (n = 17) | High (n = 28) | Total (n = 50) | |
| Complication | ||||
| Fluid collection (suprapubic) | 0 | 0 | 4 (14.2%) | 4 (8%) |
| Fluid collection (interpectoral triangle) | 0 | 0 | 1 (3.5%) | 1 (2%) |
| Fluid collection (lateral abdomen) | 0 | 0 | 1 (3.5%) | 1 (2%) |
| Fluid collection (lower back) | 0 | 1 (5.8%) | 0 | 1 (2%) |
| Fibrosis (linea alba) | 0 | 1 (5.8%) | 0 | 1 (2%) |
| Total | 0 | 2 (11.7%) | 6 (21.4%) | 8 (16%) |
Distribution of Complications in Each Group
| Extent of definition | ||||
|---|---|---|---|---|
| Mild (n = 5) | Moderate (n = 17) | High (n = 28) | Total (n = 50) | |
| Complication | ||||
| Fluid collection (suprapubic) | 0 | 0 | 4 (14.2%) | 4 (8%) |
| Fluid collection (interpectoral triangle) | 0 | 0 | 1 (3.5%) | 1 (2%) |
| Fluid collection (lateral abdomen) | 0 | 0 | 1 (3.5%) | 1 (2%) |
| Fluid collection (lower back) | 0 | 1 (5.8%) | 0 | 1 (2%) |
| Fibrosis (linea alba) | 0 | 1 (5.8%) | 0 | 1 (2%) |
| Total | 0 | 2 (11.7%) | 6 (21.4%) | 8 (16%) |
| Extent of definition | ||||
|---|---|---|---|---|
| Mild (n = 5) | Moderate (n = 17) | High (n = 28) | Total (n = 50) | |
| Complication | ||||
| Fluid collection (suprapubic) | 0 | 0 | 4 (14.2%) | 4 (8%) |
| Fluid collection (interpectoral triangle) | 0 | 0 | 1 (3.5%) | 1 (2%) |
| Fluid collection (lateral abdomen) | 0 | 0 | 1 (3.5%) | 1 (2%) |
| Fluid collection (lower back) | 0 | 1 (5.8%) | 0 | 1 (2%) |
| Fibrosis (linea alba) | 0 | 1 (5.8%) | 0 | 1 (2%) |
| Total | 0 | 2 (11.7%) | 6 (21.4%) | 8 (16%) |
Minor complication: fibrosis. Pre and post-ultrasound therapy in this 29-year-old male patient, after a mild-definition liposculpture. (A) Three months after surgery, the patient had persistent fibrosis in the linea alba and to a lesser extent in the abdominal inscriptions. (B) At 72 hours after being treated with 1 session of transcutaneous ultrasound followed by 2 sessions of manual massage (first session was the same day of the transcutaneous ultrasound treatment, second session was 48 hours later).
Patient satisfaction scores were recorded at the 6-month follow-up clinic visit. The mean satisfaction score in the MiD subgroup was 8.7 ± 0.8 (range = 7.6-9.7), in MoD subgroup 9.1 ± 0.7 (range = 8.7-9.5), and in the HD subgroup 9.3 ± 0.8 (range = 8.9-9.6). There were no statistically significant differences in these measurements between the 3 subgroups (Table 5). Also, we did not find significant differences when we compared preoperative BMI (P = 0.1) or lipo-aspirated volumes (P = 0.2) among the 3 subgroups.
Mean and Standard Deviation (SD) Values for Satisfaction and Comparison Between the Groups
| Satisfaction (0-10 scale) | Mean ± SD | Range | P value |
|---|---|---|---|
| Mild definition | 8.7 ± 0.8 | 7.6-9.7 | |
| Moderate definition | 9.1 ± 0.7 | 8.7-9.5 | |
| High definition | 9.3 ± 0.8 | 8.9-9.6 | |
| Total | 9.1 ± 0.8 | 0.2 |
| Satisfaction (0-10 scale) | Mean ± SD | Range | P value |
|---|---|---|---|
| Mild definition | 8.7 ± 0.8 | 7.6-9.7 | |
| Moderate definition | 9.1 ± 0.7 | 8.7-9.5 | |
| High definition | 9.3 ± 0.8 | 8.9-9.6 | |
| Total | 9.1 ± 0.8 | 0.2 |
Mean and Standard Deviation (SD) Values for Satisfaction and Comparison Between the Groups
| Satisfaction (0-10 scale) | Mean ± SD | Range | P value |
|---|---|---|---|
| Mild definition | 8.7 ± 0.8 | 7.6-9.7 | |
| Moderate definition | 9.1 ± 0.7 | 8.7-9.5 | |
| High definition | 9.3 ± 0.8 | 8.9-9.6 | |
| Total | 9.1 ± 0.8 | 0.2 |
| Satisfaction (0-10 scale) | Mean ± SD | Range | P value |
|---|---|---|---|
| Mild definition | 8.7 ± 0.8 | 7.6-9.7 | |
| Moderate definition | 9.1 ± 0.7 | 8.7-9.5 | |
| High definition | 9.3 ± 0.8 | 8.9-9.6 | |
| Total | 9.1 ± 0.8 | 0.2 |
DISCUSSION
Over the last 2 decades, body sculpting procedures have gained significant popularity in both male and female patients. This is mostly due to both technical and technological evolutions in this field. The extent of body definition that can be achieved now is so advanced that it has set a high bar for both surgeons and patients alike.
Based on this study, 45.5% of patients have requested MiD or MoD. This emphasizes the importance of determining the best approach in every patient on an individual basis. In terms of patient satisfaction, our results are similar to previously published data, which found an overall satisfaction rate from 95% to 98%.2,13,14 In our study, we compared the levels of satisfaction among the 3 subgroups and found that the HD subgroup had a higher, but not significantly different, satisfaction scores at 6 months postoperatively.
Other groups have reported the incidence of seromas (29.97%) in both women and men, with the interpectoral and suprasternal regions being the most frequent locations in men.15 Our study shows an overall complication rate of 16%, with seroma being the most common complication. It is a similar incidence to what we have previously published in the prospective study.6 When subgroups are analyzed and compared, the HD subgroup had the highest (21%) complication rate. This can be attributed to the more aggressive approach to treat the superficial fat layer in the HD subgroup. The most common site for seroma was the suprapubic region, which can be explained by the gravitational accumulation of fluid in this region. We believe that avoiding the utilization of thermal energy–based technologies lowers the rates of fluid collections. However, an objective high-quality study comparing PAL and thermal energy–based technologies is needed to prove the superiority of 1 technology compared with any other. No significant complications (infection, hypovolemic shock, anesthetic toxicity, anemia, thromboembolism, or death) were encountered in our series, highlighting the safety of this procedure.16
We believe that the addition of the dispersion step has helped us decrease blood levels in the aspirated fat and improve postoperative pain control through maximizing the effect of epinephrine and lidocaine respectively. The dispersion step is different than what was previously described in the literature, such as the expansion vibration concept, where tumescence fluid is injected via a vibrating device.17 In our described technique, we divide the expansion vibration into 2 separate steps. Initially, tumescence is injected without vibration, which helps achieve a less traumatic hydro-dissection and gives enough time for local effect of the tumescence fluid components on the host tissue. This is followed by the utilization of the vibration power without suction, which helps mix the tumescence components with the host tissue fat and surrounding tissue, hence maximizing the hemostatic effect of epinephrine and pain control of lidocaine. This is an opinion based on personal experience, and a well-designed randomized study is needed to objectively quantify and scientifically justify our clinical experience.
From a technical standpoint, the utilization of the low-amplitude reciprocation of the PAL technology allows the tailored approach to sculpt and define the superficial fat layer to different extents. This is achieved through a balance between suction power and reciprocation of the cannula tip. The final level of definition should be based on visual cues in the operating room and the difference in the thickness of the superficial fat and sharpness of the created edges.
In our practice, we offer patients a “menu” of definitions to choose from: mild, moderate, or high. During their initial clinic visit, we show patients 3 sets of before-and-after photographs of individuals who have had the 3 different levels of definitions to choose from, and discuss their candidacy for the selected level based on their body habitus and skin and muscle tone. We also stress the fact that body definition is more a project than just a procedure. This project starts with proper patient selection based on their comorbidities, surgical history, smoking cessation, BMI, skin quality, and, very importantly, expectations. Once deemed candidates, the level of definition can be achieved employing the techniques described earlier in this manuscript.
The postoperative course can significantly alter the final outcomes; patients should be motivated to comply with postoperative instructions, including massage, compression garment utilization, physical exercising, compliance with dietary restrictions (avoid gaining body fat but gain muscle mass instead), and scheduled follow-ups.
Although the proposed classification of the levels of definition can serve as a useful tool to deliver the results patients seek, there is still significant subjectivity in this classification because what is high definition for someone could be moderate or even low for another. This is why we recommend the utilization of before-and-after photographs to add visual sense for patients to make more educated choices.10,18
As we all know, multiple variables can influence final patient results and levels of definition. These variables include but are not limited to the intraoperative techniques, the degree of foam compression in the treated areas, compliance with the compression garment, physical exercising, adherence to postoperative instructions, and development of postoperative fibrosis. All these variables, among others, can jeopardize the intended level of definition, especially in the initial stages of a surgeon’s experience before learning how to control these variables individually. Having said that, the preoperative utilization of photographs for patients to choose from can be considered disadvantageous because it is a form of a contractual agreement. We recommend patient education about these variables and how they might influence the outcome of their surgery.
This study has its limitations. It is retrospective and uncontrolled, and the sample size is relatively small. A larger patient population is needed to improve the power of our data. Another limitation of our study is the utilization of a custom-made satisfaction questionnaire; a standardized questionnaire would have been a preferable tool to measure patient satisfaction.
CONCLUSIONS
A spectrum of definitions can be safely performed utilizing the described techniques with PAL liposuction. As we demonstrated in this study, high patient satisfaction can be achieved in mild-, moderate-, and high-definition liposculpture with low complication rates. We strongly recommend a thorough patient selection process, adherence to the surgical principles described in this manuscript, and thorough patient guidance through their postoperative course. The techniques and data presented in this paper can be utilized as a guideline for surgeons to replicate our results and offer their patients a “menu” of definitions to choose from.
Disclosures
Dr Saad is a consultant for Microaire (Charlottesville, VA).
Funding
The authors received no financial support for the research, authorship, and publication of this article.
REFERENCES
