**1. Introduction**

A brief historic introduction to liposuction and surgical body contouring, the method has been around since the 1970's. Developed and enhanced throughout the passing years, most notably in 1988 by Michele Zocchi. The ultrasound assisted liposuction (UAL) method was created and used in 1,057 patients (875 women and 182 men) from 1989 to 1996, by Zocchi [1]. He was able to remove larger quantities of fat than the manual liposuction method and suggested that this technique had great potential in treating specific patients. The results are excellent and with no major complications, opening the door to a more effective liposuction method. Of the minor complications encountered, there were mild burns at cannula sites and discoloration of skin (dyschromia).

Further technique development and increased popularity began in the 21st century, with Alfredo E. Hoyos. He introduced high-definition body sculpturing [2–4].

VASER liposuction means vibration amplification of sound energy at resonance (VASER).

VASER ultrasound technology enables the fragmenting of large fat into smaller fat pieces. The method uses an infiltration technique with tumescent fluid comprised of a combination of saline, adrenalin, lidocaine and sodium bicarbonate. The released fat molecules are then extracted from the body using liposuction cannulas. A more sparring and less aggressive manual extraction is needed with this method, than what is used with the classic liposuction technique [5, 6].

The use of tumescent fluid not only releases the fat molecules but also reduces bleeding and provides analgesia.

A presentation and discussion of the VASER modes used (continuous or intermittent), tumescent fluid (amounts and preparation), method of achieving natural results, differences between sexes and areas being treated will all be covered thoroughly.

My personal experience with liposuction began in 2008, as a plastic surgery resident. Attending several congresses, notably an annual Congress of the Turkish Society of plastic Surgery in Istanbul. There an American surgeon, Mark Jewell, described VASER as, "the best thing to ever happen to him in his life". He stated, "this method gave significant better results compared to earlier methods" [7]. This was intriguing and Polyclinic Bagatin purchased the device and began implementing it, after several hands on courses. The results were immediate. The method of liposuction was easier and more efficient in fat extraction. At the start, several patients (5–10%) had to have additional corrections until the technique was perfected. However, results were good, and patients were very satisfied. There were a few cases where the results were not as anticipated. Even after attempted corrections, the results were not great. This suggests actual limitations of the VASER technique in some cases [8–10].

Overall, it is always important and crucial to listen to patients what they want and what can be realistically achieved [11]. It is better not to make promises that cannot be kept. An honest open approach is best as to what can be done. Results depend on patient age, skin quality, amount of fat deposits and their locations, as well as eating and drinking habits and patient motivation. An ideal patient is one who knows exactly what they want, realistic expectations, good skin tone and texture.

## **2. Materials and methods**

Performing an ultrasound assisted liposuction method involves thorough preparation and planning.

Patient candidate consultation, discussion, planning, visual aids (VECTRA, drawings, examples of results) and clear achievement goals are needed prior to operating.

Once a goal and plan has been reached, the operating team is debriefed and steps to start the procedure can begin.

Klein's original fluid combination uses saline, a local anesthetic (lidocaine), a vasoconstrictor (adrenaline), and sodium bicarbonate. Dr. Klein uses for each 1000 mLs of saline, 12.5 mL sodium bicarbonate (8.4%), 0.5–0.75 mg adrenaline, and lidocaine 500 mg (using up to a maximum of 55 mg/kg patient body weight) [12]. At Poliklinika Bagatin a significantly lower maximal dose is used,


*VASER Liposuction - How to Get Natural Results with Ultrasound Assisted Liposuction? DOI: http://dx.doi.org/10.5772/intechopen.100154*

#### **Table 1.**

*Tumescent solution variations.*

35–45 mg/kg. Interestingly, Hunstad created a modified solution using a 500 mg lidocaine within 1000 ml Ringer Lactate and 1 mg of adrenaline [12]. However, Dr. Hunstad opts not to use sodium bicarbonate in his modified solution. Various mixtures of tumescent fluids are used worldwide. Others such as Pitman, Toledo and Zocchi, as seen in the table provided, have their preferred combinations (**Table 1**).

#### **3. Various combinations of tumescent solutions**

Whatever the variations used, in general a mix of similar ingredients are combined.

The tumescent fluid is prepared using a specified amount of saline required for certain areas of the body. This depends on body surface area to be performed on. For example, the chest can require 3–4 liters, while the legs or arms may need 1–3 liters. The abdomen may require 6 liters. The surgeon decides on volume amounts, reducing this if multiple operative sites are to be performed, with or without surgical reduction.

At Poliklinika Bagatin, each liter of tumescent fluid used is a combination of standard intravenous saline, 1 mg adrenaline (epinephrine), 10 mL bupivacaine (5 mg/mL), and 10 mL sodium bicarbonate (8.4% w/v) [13]. More than 35–45 mg/kg bupivacaine in total, is never used [14, 15], reducing the risks of possible overdosage. A larger amount of anesthetic can be used, since it will not be placed intravascularly, is combined with adrenaline and the majority will be removed during extraction liposuction. The half-life of lidocaine and bupivacaine is about 2–2.5 hours and both are metabolized 90% hepatically. The procedures are often lengthy, and can last more than 3 hours. This further reduces the possibility of local anesthetic toxicity.

The final tumescent solution looks similar in color to champagne.

Patient preparation is performed as usual, from preoperative anesthesia exam, induction, monitoring, surgical wash and sterile drape coverings.

Following the standard surgical time out, infiltration with 20mLs tumescent fluid (for easier application) is used to infiltrate areas where ports will be placed. Ports are protective portholes used for the various cannulas (VASER, liposuction VentX, infiltration probe), and protect the skin surface areas below from thermic burns that can occur without using them. The ports used are a standard diameter of 3.7 mm. Skin incisions for the ports are 3 to 5 mm wide. Care is taken to carefully choose positions, of these port incision areas, as well as how many ports will be placed. This is important for achieving natural and proper results.

When the ports are in place, tissue infiltration with the remaining tumescent fluid begins with the infiltration apparatus (**Figure 1**).

The infiltration device has various injection settings. Each are used specifically to apply the tumescent fluid into various layers and depths in the areas being treated. Surface layers are injected using the VASER variable flow (start-stop-start). While deeper layers are injected with a continuous flow. This is important to protect against burns and bleeding of more sensitive surface layers. The flow rate used is not faster than 100mLs per minute.

Following the successful tumescent fluid application, there is a waiting time (cooking time) of 10–15 minutes. During this time, fat cells are enabled to bloat and

**Figure 1.** *VASER machine.*

*VASER Liposuction - How to Get Natural Results with Ultrasound Assisted Liposuction? DOI: http://dx.doi.org/10.5772/intechopen.100154*

explode into smaller fatty fragments, which will then be more easily extracted by the various cannulas.

The tumescent fluid is prepared using a specified amount of saline required for certain areas of the body. This depends on body surface area to be performed on. For example, the chest can require 3–4 liters, while the legs or arms may need 1–3 liters. The abdomen may require 6 liters. The surgeon decides on this amount by determining operative site area, as well as procedure to be performed (possible surgical combination of area reduction).

Each liter of tumescent fluid used is a combination of standard intravenous saline, 1 mg adrenaline (epinephrine), 10 mL bupivacaine (5 mg/mL), and 10 mL sodium bicarbonate (8.4% w/v) [12]. More than 35–45 mg/kg bupivacaine, in total, is never used [13, 14], reducing the risks of possible overdosage. A larger amount of anesthetic can be used, since it will not be placed intravascularly, and the majority will be removed during extraction liposuction.

When the ports are in place, tissue infiltration with the remaining tumescent fluid begins with the infiltration apparatus (**Figures 2**–**4**).

The infiltration device has various injection settings. Each are used specifically to apply the tumescent fluid into various layers and depths in the areas being treated. Surface layers are injected using the VASER variable flow (start-stop-start). While deeper layers are injected with a continuous flow. This is important to protect against burns and bleeding of more sensitive surface layers. The flow rate used is not faster than 100mLs per minute.

Following the successful tumescent fluid application, there is a waiting time (cooking time) of 10–15 minutes. During this time, fat cells are enabled to bloat and explode into smaller fatty fragments, which will then be more easily extracted by the various cannulas.

High-definition extraction can be achieved in various regions of the body. A gentle fanning, in-out motion of the cannulas is used. This process is continued until desired results are achieved. Following maximal extraction, it is mandatory to place overflow release drains. This helps reduce formation of seromas and faster normalization of the liposuction area, removing excess remaining trapped fluid and reducing build

**Figure 2.** *All needed instruments for VASER liposuction.*

**Figure 3.** *Two rings VASER probe.*

**Figure 4.** *Standard 3,7 mm VentX cannula.*

up. Patient follow-ups need to be frequent, recommended daily for the first 7 days. During the early postoperative period, deformities are possible and can be then attended to, before becoming permanent. Later, if any lasting deformities present, they can be corrected a year after the initial operation. This is important to allow all tissues to heal, settle into a formed position and give a final view of procedure results.
