*3.4.2 Final conclusion*

Jowls, neck, upper arms, axillae, bra rolls (midback), flanks, hips, abdomen, male chest, female breast, medial/lateral thighs, and knees were among the common areas treated using radio frequency assisted liposuction. **Figure 12** showing Pre and Post surgery photographs of patient who has undergone RFAL liposuction of the arms.

The procedure usually takes 90–120 minutes to complete, with a tumescent injection volume of approximately 2000 mL.

The mean temperatures outside and inside were 35–42°C and 50–70°C, respectively. Following the protocols, all patients would be discharged home, with followup appointments set for one week and three months afterward.

#### **Figure 12.**

*(A and C) Pre-operative photograph of a 50 year old lady who has fat deposits with moderate skin laxicity in her arms. RFAL can achieve consistent and reproducible results with excellent soft tissue contraction as seen in the above post-operative images 12 weeks after surgery (B and D).*

#### *3.4.3 Complications*

Temporary weakness of the marginal branch of the mandibular nerve caused ipsilateral weakness of the depressor anguli oris was observed in one case of neck and lower face RFAL. After 5 weeks of monitoring and no action, the issue was finally resolved. Two patients with burns were published in a report [35].

#### **3.5 Laser assisted liposuction**

In 1990, a 34-year-old man with abdominal lipodystrophy underwent the first laser-assisted lipoplasty under an IRB procedure. The findings of a multicenter analysis of the laser-assisted liposuction system were announced by Apfelberg et al. [36, 37] and Fodor [38]. There were 51 patients in the study, 15 of whom had laserassisted liposuction on one side and traditional liposuction on the other. The lasertreated areas had somewhat less discomfort, edema, and ecchymosis, but the hematocrit findings were inconclusive.

The effect of low-level transcutaneous 635-nm, 10-mW diode laser radiation on the subcutaneous fat was studied by Neira et al. [39] in 2002. On human adipose tissue taken from lipectomy samples of 12 patients, total energy values of 1.2, 2.4, and 3.6 J/cm2 were added. Transmission electron microscopy and scanning electron

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

microscopy were used where the standard adipose tissue appeared as clusters of grapes without laser exposure. 80 percent of the fat was released from adipocytes after 4 minutes of laser exposure, and 99 percent of the fat was released after 6 minutes of laser exposure. The fat that had been released had accumulated in the interstitial space. At 60,000 magnification, transmission electron microscopic images of adipose tissue revealed that the adipose cell was affected by the low-level laser energy by causing a transitory pore in the cell membrane to expand, allowing the fat content to escape from the cells.

The interstitial space cells and capillaries remained unharmed. Since red light (635 nm) does not penetrate effectively underneath the skin surface and into the subdermal tissues, Brown concluded that low-level laser therapy is ineffective. The word "greatest active depth" refers to the point at which the light intensity is so minimal that no biological impact can be measured. Just 0.3 percent of laser photons penetrate to a depth of 2.0 cm in a 50 mW/cm2 exposure.

By 2005, laser lipoplasty (SmartLipo, Deka, Florence, Italy) as seen in **Figure 13** with a pulsed 1,064nmNd:YAG laser was commonly used in Europe and Latin America, and had recently been introduced in Japan and the United States. The SmartLipo hand piece is a cannula with a handle that has a diameter of 1 mm. The glass laser fiber extends through the cannula to the open end, and the laser energy is directed to the fat from the cannula tip. On the market, this cannula was the first socalled bare fiber free beam laser lipolysis kit. On October 31, 2006, Cynosure obtained FDA approval for the Smart Lipo product for sale in the United States.

**Figure 13.** *The Smart Lipo machine by Deka with a pulsed 1064 nm Nd:YAG laser.*

#### *3.5.1 Technique*

The tumescent anesthesia technique remains the same as mentioned in 3.1 above. After waiting for an adequate period of time the laser cannula is slowly passed through the tissue to achieve lipolysis in the different levels of fat (superficial, medium, and deep) and into the subdermal plane where enough accumulated energy must be delivered. When the laser is used in the subdermal plane, the skin feels warm to the touch. Once the laser was used for lipolysis, the fat was aspirated using a 3 mm liposuction cannula. Acute adipocyte rupture and subdermal collagen band rupture is seen in histological studies. Tiny areas of fat deposits, areas with moderate or possible flaccidity, highly vascular areas, and secondary liposuction with defects, fibrosis, or other difficult cases are ideally suited for this procedure, which takes longer than traditional liposuction.

LAL is a surgery technique that has been recently introduced. However, credible studies comparing its advantages, protective features and effectiveness to those of the well-established technique of conventional liposuction are lacking. Five studies [40–44] indicated that LAL has advantages over conventional liposuction, and only two [45, 46] failed to find statistically significant differences between the techniques in the evaluated endpoints. Histological review [40, 42] shows that subcutaneous fat reduction [41, 43], skin retraction [41–43] and patient satisfaction [41, 43] were the key endpoints assessed in the studies.

Patients who have conventional liposuction procedures can experience ecchymosis, bleeding, and discomfort, which may lead to a longer recovery time [47] Jecan's [40] histological research shows that the LAL technique has potential benefits over the traditional technique, such as the protection of nerve endings and increased blood vessel clotting with less blood loss and milder grades of ecchymosis. Furthermore, the coagulation-modified collagen seen by microscopy could clarify the esthetic advantage of skin retraction after laser use, as shown in other studies [48].

However, promising outcomes in histological evaluations should be backed up by randomized trials that look at specific clinical endpoints.

Two studies [41, 43] found that the LAL technique produced superior results in terms of subcutaneous fat reduction as measured by ultrasound analysis after the procedure. The use of a laser could potentially aid in the destruction of adipocyte membranes, making removal simpler and more uniform, as well as improving the clotting of tiny blood vessels and lymphatic vases. Huge amounts of fat may be eliminated thanks to these benefits, reducing the risk of hemodynamic complications [49, 50].

LAL has the ability to cause collagen formation as well as fatty tissue rupture and liquefaction, allowing for further remodeling and skin retraction [50–52]. Wolfenson's major skin retraction could mean that the use of a dual-wavelength diode laser (924–975 nm) allows for subcutaneous cell tissue and deep dermis remodeling. The most important advantage of laser-assisted liposuction is the skin tightening effect. For that to occur, as previously described, achieved internal temperature should be within the 48–50°C range. That temperature promotes desired thermal injury within the dermis (**Figure 14A**). Subsequently the physiologic healing process is initiated which leads to fibroblast stimulation and neocollagenesis. At the same time, the heat itself shrinks the existing collagen. The final effect is superior skin redraping. Significant decrease in blood loss can be observed during the laser-assisted vs. conventional liposuction. Goldman reported coagulated blood vessels in fatty tissue in the histological analysis of lipolytic tissue.

The use of laser during the liposuction procedures enables the use of smaller cannulas. The fat is being liquefied during the laser lipolysis and in the melted form *Use of Technologies to Improve the Liposuction Outcome Including Skin Texture and Form DOI: http://dx.doi.org/10.5772/intechopen.99947*

#### **Figure 14.**

*(A) Laser fiber being used for lipolysis in the cervicofacial area. A red colored hue can be seen in the subcutaneous layer when the laser is fired. Patient pre (B) and (C) 7 days post-operative photographs in a 48 year old lady who had lost her jawline due to weight gain.*

can be suctioned through smaller cannulas. The liquefaction of fat combined with smaller cannulas for suction enable the treatment of smaller areas as well as the areas that are highly fibrous and where the fat is enclosed in smaller compartments. That advantage is especially significant when treating post-liposuction irregularities, face, male chest, knees, hips and back. **Figure 14B** and **C** are the pre and post photographs of a lady who has undergone cervico facial Liposuction.
