**3. Material and methods**

The Authors have used the below mentioned technologies over the last 15 years and hence this section is dedicated to a discussion about individual technologies, their indications with respect to body contouring, method of undertaking the procedure, long term results of some patients who have undergone the procedures along with the complications that may be associated with the procedure.

#### **3.1 Ultra sound assisted liposuction**

Zocchi [7] is credited with the first person to use ultrasonic energy to more specifically target adipose tissue. The prototype UAL was a two-stage process that involved first breaking or lysing the fat followed by its suction. It began with use of 4–6 mm solid titanium probes which in contrast to steel, was better to harness the heat released by converting acoustic to mechanical energy. Electric energy is converted into mechanical energy using piezoelectric or quartz crystals, which is then transmitted and magnified by the probe as high-frequency (in excess of 16 kHz) acoustic energy inaudible to the human ear. The sound wave has alternating expansion and compression sections which produces negative pressure and induces an interstitial cavity, hence the term cavitation (**Figure 2**).

These microbubbles ultimately implode, resulting in cellular fragmentation and intracellular material release [7, 11]. The selectivity and tissue specificity of UAL are based on the assumption that this happens most rapidly with adipose tissue. Since this method generates a lot of heat, there should be plenty of wetting solution to aid dispersion and limit any negative thermal effects. The technological end point varies from SAL in that it is not simply the traditional 'pinch test,' but lack of resistance to probe progression that suggests adipocyte liquefaction and the 'end point'. Lipoaspirate is also homogeneous and macroscopically acellular, with a slightly higher level of the intracellular glycerol 3-phosphate dehydrogenase isozyme unique to adipocytes [12].

#### **Figure 2.**

*The compression and rarefaction of the ultrasound waves causing breakage of the fat cells.*

American doctors accepted UAL leading to the creation of second-generation UAL devices with hollow cannulae for simultaneous aspiration [13]. Unfortunately, the wetting solution's simultaneous cooling effect is lost which led to the appearance of third-generation machines.

The VASER® (Vibration Amplification of Sound Energy at Resonance, Sound Surgical Technologies, Louisville, CO, USA) device [14] is one of the most commonly used. It comes in two models (**Figure 3**).

**Figure 3.** *VASER machine with its probes and other accessories.*

#### *Use of Technologies to Improve the Liposuction Outcome Including Skin Texture and Form DOI: http://dx.doi.org/10.5772/intechopen.99947*

The first uses pulsed energy rather than continuous energy, and the second uses concentric rings near the narrower (2.9–3.7 mm) probe tip to maximize performance. At lower and safer energy environments, substantially greater fragmentation efficiency can be achieved [15].

The VASER system uses a method for pretreating fatty tissue with ultrasonic energy, which induces fragmentation/emulsification by three biologic effects, similar to the previous devices.


When ultrasonic waves reach their higher amplitude plateau, they cause expansion and when the ultrasonic waves reach their lower amplitude plateau it is followed by passive contraction of the gaps, resulting in a cycle of active expansion and passive contraction. The frequency at which the cycles occur, however, prevents the contraction process from being completed before the expansion cycle starts again. As a result, the gaps grow wider until they exceed 120 metres and implode, rupturing the cellular membrane and releasing the lipid content into the extracellular environment [16–18].

Tiny diameter titanium solid probes (2.9 and 3.7 mm) with grooves near the tip are used in the VASER method to improve fragmentation efficiency (**Figure 3**). The grooves close to the tip redistribute ultrasound energy and move some vibration from the tip to a region proximal to the tip. Less energy is thus needed to achieve the desired fatty tissue fragmentation due to the improved efficiency. As compared to the continuous mode, the probe design will result in a nearly 50% reduction in applied power with improved fragmentation capability. Another important difference is that the handpiece and instrumentation of the VASER system are lighter, smaller, less bulky, and more convenient than those of previous systems [19–22].

#### **3.2 Vaser lipoplasty technique**

For any procedure involving liposuction and body contouring pre – operative marking with the patient standing, is a must. Once marking is done and after administrating Local or General Anesthesia. The tumescent fluid is infiltrated to the planned operating site, until the skin is blanched. The tumescent fluid composition used by us is mentioned below.

Tumescent fluid composition:

Lidocaine – 35 – 55 mg/kg body weight.

Epinephrine – 1: 1000000 meq/ body wt.

Sodium Bicarbonate – 12.3 meq / body wt.

Hyaluronidase – 1500 IU/ 1000 ml of fluid.

Ringer Lactate / Normal Saline – Mix all in 1 liter.

A minimum of 7–10 mins after the infiltration is required for the vasoconstrictive effects to take place. The access incisions of 4-5 mm are made using 11 no: blade and skin protectors (ceramic or plastic) are placed. They're made to prevent injury

to the incision edges during the fragmentation process [19]. The skin near the port should be covered with a wet towel to prevent unintended burn lesions if a probe comes into contact with exposed skin. This safety is particularly important in curved areas, where the surgeon's maneuvers to reach the treatment area can expose the skin to probe touch causing collateral damage due to the heat generated.

The first step in the VASER use is to create tunnels in the subcutaneous area so as to prevent damage to the Ultrasound probe. The probe must then be inserted via the port; simple axial back-and-forth motions should be used, with no levering to the sides or up and down. Without unnecessary pressing, the probe should be pushed smoothly at a pace that the tissue and VASER settings allow. It's best to travel at a pace that's close to or slightly slower than normal suction cannula movement. The probe should never be stationary and should always be kept moving parallel to the skin.

Cross-tunneling is highly desirable and should be used wherever possible to achieve more uniform emulsification and better aspiration. If the probe is vibrated in the air, it can cause damage hence the distal 1 or 2 cm of the probe must always be in contact with tissue or fluids or within the skin port and subcutaneous tissue. End-hits and scratching the dermis from below should be avoided to prevent burns to the skin.

The diameter of the probe and the amount of grooves on the tip has an effect on how well it penetrates any given tissue. Probes with more grooves emulsify fat tissue more effectively for a given diameter, but they do not easily penetrate fibrous tissues due to the large amount of vibratory energy transmitted to the sides of the probe rather than the tip.

For fibrous tissues, probes with less grooves are better. Apart from the number of grooves, smaller diameter probes penetrate fibrous tissues more easily. The 3.7 mm probes are designed for rapid debulking and contouring of soft to fibrous tissues in medium to large volumes. The 2.9-mm probes are used for fine contouring and treating smaller soft to highly fibrous localized fat deposits and sensitive areas.

In general, the continuous mode should be used in fibrous tissues for faster fragmentation and when tissue emulsification with the VASER mode is difficult. For more delicate work, finer sculpting, or softer tissues, use the VASER mode. The probe must pass smoothly through the tissue after the system has been calibrated. If the probe fails or drags, the amplitude should be increased, or a probe with less grooves or a smaller diameter should be chosen.

Initial application times with the VASER or continuous mode are recommended to be no more than 1 minute per 200 mL of infused solution, but this method typically results in only partial fragmentation of a targeted area. The manufacturer recommends these settings, but experience and practice allow for up to 1 minute per 100 mL infused. In general, the surgical endpoint occurs anywhere between the tissues' loss of resistance to the probe and that according to the time guidelines.

Suction-assisted lipoplasty or power-assisted lipoplasty may be used to aspirate the targeted localized fat deposits after emulsification [19–26]. Additional aspiration may be needed for optimum esthetic refinement, and since the site is dry, the probe cannot be reapplied after aspiration. Sutures are used to close the incisions, and a typical liposuction postoperative treatment begins.

#### *3.2.1 Clinical outcome*

When used in combination with suction-assisted lipoplasty or power-assisted lipoplasty, the VASER system operates in a complementary manner. It's a fatty tissue pretreatment process that uses ultrasound energy to fragment/emulsify fat before aspiration. It uses the least amount of ultrasound power possible to precondition fatty tissue for subsequent aspiration while preventing damage to other

*Use of Technologies to Improve the Liposuction Outcome Including Skin Texture and Form DOI: http://dx.doi.org/10.5772/intechopen.99947*

elements of the tissue matrix and surrounding tissues thanks to its smaller diameter and specially built probes. Without extending the operative time, it is possible to treat a larger number of area with more cross tunnels for more consistent fragmentation as seen in **Figure 4**.

Histochemical analysis of the aspirate confirmed 70 percent to 90 percent cellular disruption when using VASER energy. Ultrasound energy splits the cellular membrane and releases the lipid content into the extracellular environment, but it does not induce the release of fatty acids from the triglyceride molecular structure, so the fat tissue that remains is not damaged.

#### **Figure 4.**

*(A) VASER technology being undertaken on the back with cross tunneling. The photograph shows the VASER probe being used to melt fat. Note the skin protection using a ceramic shield. (B) Pre and (C) post procedure photographs (4 weeks after surgery) of a 32 year old male patient who lost 10 kgs with diet and exercise and further wanted to shape his body to get a flat abdomen and not so protruding chest underwent VASER assisted liposuction.*

#### *3.2.2 Complications*

The most recent series comparing the VASER device to first- and secondgeneration UAL devices found that the VASER device has a low to zero incidence of complications, while the average incidence of complications with earlier UAL devices is about 5%. Seromas or delayed bursa formation, prolonged dysesthesias, burns, induration, contour irregularities, hyperpigmentation, cellulitis, and prolonged swelling are the most common UAL complications, although these have been attributed to the use of excessive energy or prolonged application. When it comes to neural injury, studies have shown that the length of exposure is more important than the use of ultrasound energy.

The lower need for energy required for emulsification due to the optimization of the applied energy by the grooved probes and the pulsed emission of energy in the VASER mode may explain the lower incidence of such complications with the use of VASER. Burns and ischemic injuries associated with UAL systems have been documented in the literature, and they tend to be linked to execution issues such as end-hitting and intimate contact with the dermis from below [19].

#### **3.3 Water jet assisted liposuction**

A small, targeted, fan-shaped jet called Body-Jet (Human Med, Mecklenburg-West Pomerania, Germany) (**Figure 5**) is used to infuse fluid during water jet– assisted lipoplasty (WAL) (**Figure 6**). The fluid's goal is to loosen fat cells with as

**Figure 5.** *Water jet device.*

*Use of Technologies to Improve the Liposuction Outcome Including Skin Texture and Form DOI: http://dx.doi.org/10.5772/intechopen.99947*

#### **Figure 6.** *The fan shaped jet of water infused into the tissues.*

little collateral damage as possible, rather than cutting sharply through tissue. The jet is guided into adipose tissue to loosen the tissue structure and allow adipocytes to escape. This is an active method that replaces the conventional passive fluid entry processes of diffusion and osmosis [27].
