**5.3 VASER liposuction**

With the use of PAL, the tumescent solution is infiltrated with a 3 mm basket cannula (**Figure 5**). The average infiltration of tumescent amount is approximately a ratio of 1:1-1:5. Vibration from PAL infiltration of tumescent solution can be a helpful sensory distraction for patients having surgery under local anesthesia. Furthermore, PAL allows for even infiltration throughout tissues even in presence of significant scarring due to previous liposuction or other non-invasive fat reduction procedures such as cryolipolysis or deoxycholic acid injections [23, 24]. A UAL probe of 3 mm is used for fat emulsification followed by lipoaspiration with SAL, again using a 3 mm cannula. Our standard VASER settings are between 60 and 70% on VASER mode for fat emulsification and pre-tunneling in both the deep and superficial fatty layers of the arm. Tissue treatment with VASER is always performed in both the deep and superficial layers even if only deep liposuction is planned. Superficial fatty layer treatment with VASER provides a modest degree of skin tightening which may be sufficient on its own or can be coupled with other technologies as necessary. Deep liposuction below the superficial fascia layer (deep/lamellar fat layer) can be carried out aggressively in order to debulk areas of excess adiposity in the posterior arm region with limited risk of creating contour abnormalities. It is important to address lipodystrophy around the distal arm/elbow region as well as the anterior and posterior axillary folds as necessary. These regions are best addressed with small and short cannulas for focused liposuction with limited restriction in arc of instrument movement.

*Enhanced Lipocontouring of the Arms DOI: http://dx.doi.org/10.5772/intechopen.98807*

#### **Figure 5.**

*Typical devices using during enhanced arm liposuction in our practice: (A) power-assisted device with gentle basket cannula for tumescence fluid infiltration (PAL, MicroAire surgical instruments, Charlottesville, VA); (B) VASER probe; (C) 3 mm curved suction-assisted liposuction (SAL) cannula; (D) subdermal radiofrequency (RF) device (Renuvion, 15 cm probe).*

Strategic superficial liposuction may be carried out if required and/or when muscular etching is being performed. The authors try to avoid a complete 360° release of subcutaneous fat when possible as fat removal from the external zone of the arm is often limited or even unnecessary. Avoiding a complete 360° surgical release may allow for earlier resolution of swelling by decreasing the disruption of the venous and lymphatic systems. The addition of lateral chest wall liposuction if excess bulk is present there can provide added benefit by making the arms seem smaller as there is less tissue pushing the bulk of the arms out when adducted.

#### *5.3.1 Artistic enhancement*

To further enhance results of arm liposuction, we can incorporate the concepts of muscular etching [4] into the planning. For enhanced muscular definition and etching, careful compression while liposuctioning with a curved cannula is used to gradually create depression at the border of the muscle as desired. This is an advanced technique that should be gradually adopted as the surgeon gains experience and confidence in arm contouring [4]. Compression during liposuction elsewhere is not recommended as unwanted and difficult-to-correct depressions and irregularities can develop rapidly.

Removing a small amount of fat superficially to increase the definition of the anterior and posterior edges of the deltoid can push the aesthetic caliber of the result in arm liposuction. The posterior tricipital groove is not as clearly defined in all patients but is a pleasing appearance in lean, more muscular female and male patients and can be enhanced with superficial liposuction when in synchrony with the patient's body shape. Biceps enhancement with superficial liposuction in the anterior bicipital groove in our practice is less common and mostly performed for male patients. Care must be taken to protect underlying neurovascular structures.

The addition of fat grafting at this stage to further enhance results, particularly into the deltoid and occasionally into the biceps muscles, can help patients achieve the desired muscular definition that they are looking for [4]. Typically, a small amount of fat grafting of less than 50 cc per arm intramuscularly can achieve this result.

#### **5.4 Skin tightening with RF**

The thin nature of the arm skin has made it a challenging area for liposuction (similar to the medial thighs). Assessing the skin quality is critical. Many patients with arm skin laxity would prefer to be left with some loose skin and avoid the telltale sign of a brachioplasty scar. The adjunct use of RF can also possibly concert a patient who may have required a full, long brachioplasty scar to a shorter scar, limited to the mid upper arm.

The use of subcutaneous RF techniques have been beneficial in further improving skin tightening and quality [6, 9]. RF subdermal skin tightening is more powerful and is particularly advantageous as it avoids targeting dermal chromophores and epidermal injury, thus can be used in any Fitzpatrick skin type, unlike transdermal RF and laser treatments [12].

#### *5.4.1 Subdermal RF*

When incorporating subdermal RF into the treatment plan, tumescence followed by UAL of the deep and superficial adipose tissue is carried out first. Treatment with subcutaneous heating of the Renuvion device follows completion of liposuction. The area for RF treatment is divided into ergonomic, accessible sections for the surgeon. Typically in the arm, we have three zones for RF treatment (posterior, posterior-internal, and posterior-external). There must be a minimum of two access points on the arm to allow for egress of the helium gas. Treatments in the zone are performed by the radial application of RF energy on the outstroke only at speed of 1-1.5 cm/s. Care is taken to avoid applying energy within a 2-5 cm arc of the access incision to prevent overtreatment and the possibility of a burn. Each zone is treated with three passes only, then we move on to the subsequent area. Once all areas are treated, we retreat all zones with another three passes. This 3 + 3 technique avoids the deposition of excessive heat energy and possible injury. As per Duncan, a 10 x 15 cm segment of tissue is usually treated with approximately 5 kJ [14]. Surface skin heating is not an endpoint with this technology, unlike other energy devices, and may actually imply excessive energy delivery. Care is taken to avoid tenting of the probe underneath the dermis and to keep the probe in constant motion during energy activation. After completing RF, fine cannula SAL is gently used as a final stage to evacuate any residual helium gas and to correct fine irregularities.

Some surgeons advocate for the creation of an "internal seam" by depositing additional RF energy along the posterior border of the arm ("triceps midline meridian") [6]. We typically avoid concentrating energy deposition in a given location as it can result in irregular contraction and palpable fibrosis. Sufficient tissue tightening and circumferential volumetric contraction can be achieved with a systematic application of RF energy with limited overlapping.
