**3. Materials and methods**

The authors have been using laser assisted liposuction for the past 12 years. The laser used is the diode laser 1470 nm. The settings are as follows: 12w (for abdomen, flanks, back, legs, pseudogynecomastia), 10w for the arms and 6w for the facial area and the submental fat with continuous wave in all areas besides the face (discontinuous wave is used in the face for safety reasons).

There are many advocates for performing liposuction in solely tumescent anesthesia but the authors suggest performing only smaller areas in such manner. If the laser assisted technique is used to achieve skin tightening, the treated area should be wider than the fat accumulation to allow good adaptation of the skin. The authors always perform liposuction under general anesthesia unless the treated area is small (face, flanks of knee area). When treating the submental area in tumescent or local anesthesia one should bear in mind that postoperative nerve palsy can emerge from the lidocaine effect and not due to the intraoperative nerve injury.

The disinfection is made while patient is awake and in standing position and subsequently positioned on the sterile operating table to avoid bacterial contamination.

It is recommended to infiltrate the tumescent fluid (or 0.9%NaCl with epinephrine in 1 L/1 ml 1:1000 ratio when surgery is performed under general anesthesia to avoid the risk of lidocaine toxicity) with the infiltration pump. The use of the pump enables faster performance and uniform fluid distribution. The mechanical pressure on the tissue made by the pump contributes to vasoconstriction and fat cell disruption.

When blanching of the area is achieved, the laser lipolysis can be performed. The back and forth movements of the laser fiber in the tissue should be smooth- the fat cells should be disrupted by the energy applied and not mechanically. The pop-corn sound effect should constantly be heard as a result of laser-tissue interaction. (Video 1, Video 2) Some lasers are equipped with internal thermometer to avoid overheating and subsequent burn and necrosis. If there is no internal subcutaneous thermometer (>50°C), external thermometer can be used as a control (38-42°C should not be exceeded) but authors suggest constantly moving the undominant hand over the treated area in order to feel the surface temperature and avoid the overaccumulation of energy. Cold packs can also be used to diminish the temperature of the skin. That is also why the laser fiber has to be in constant movement and care should be taken when treating areas near muscular sheath and near the skin (the former can cause rhabdomyolysis and postoperative pain and the latter can cause burn and necrosis). The laser fiber can be stopped at one place and more energy applied during few seconds if there is significant fibrosis and resistance. It is recommended to melt the deeper layer first followed with the superficial layer. When treating the pseudogynecomastia with some amount of ptosis, it is advisable to apply the energy on the breast but also around it-lateral chest and superior to the breast to induce the collagen formation and subsequent skin retraction (**Figure 1**).

Once the lysis is finished (no pop-corn sound, no resistance when passing the laser fiber, satisfactory pinch test), the standard suction is performed. Various reports exist on lysis only (without suction) but authors suggest to suction the melted fat whenever possible to avoid complications (contour irregularities, infection, seroma formation). The suction of the liquefied fat should be smooth without putting a lot of strain to the surgeon (there is no mechanical disruption of the fat). Pinch test should be performed to assess the amount of residual subcutaneous liquefied fat throughout the suctioning procedure (**Figures 2** and **3**).

In cases with skin laxity, additional pass of the laser fiber is performed at the end of the procedure in order to apply the energy on the remaining fibrous septa and the dermis to promote the collagen formation. If the laser beam is one-directional it can be rotated towards the skin (**Figure 4**).

#### **Figure 1.**

*The arrows mark the area that should be treated with laser lipolysis only without subsequent suction to induce the collagen formation.*

**Figure 2.** *Pinch test at the beginning of the suctioning.*

#### **Figure 4.**

*Directing the laser beam towrads the skin at the end of the procedure.*

Also, when performing high-definition laser-assisted liposuction, additional energy is applied on the previously marked muscle borders over the tendinous parts of the muscle to emphasize the muscular definition. Additional incisions for laser entrance are made if necessary.

Incisions can be closed with one suture or left open especially if treating larger amounts of fat to allow the drainage. If significant fluid leak is expected, penrose drainage can be placed on the incision site upon discharge.

Postoperative garments are of the utter importance in achieving the skin retraction and its good adaptation on the underlying surface. The authors suggest wearing postoperative garments for 3 weeks. Also, additional support is put over abdomen, male breast and/or flanks. That support should be made of not too rigid, yet flexible material that can be tailored upon every patient individually (between the ribcage and iliac crests) to minimize the dead space. To avoid ischemic complications of the skin, the sponge or cotton wool can be placed on its inner surface.) Those additional plates are put in place during the first postoperative week.

When performing high-definition laser assisted liposuction, adhesive bandages are placed on the tendinous parts of the muscles (were at the end of the procedure additional pass of the energy was applied to promote neocollagenesis). Those bandages are put in place for 7 days.t

## **4. Results**

Although there are many advocates for the use of laser assisted procedure only in certain indications, the authors always perform laser-assisted procedure. It is important to bear in mind that for the final result to be achieved, it could take up to 3 months due to the prolonged effect of the laser energy.

#### **4.1 Body**

#### *4.1.1 Case 1*

48-year-old female patient.

Procedure performed: laser-assisted liposuction of the abdomen, flanks, lower back and upper legs (**Figures 5**–**7**).

**Figure 5.** *(a) Before. (b) after 3 weeks.*

**Figure 6.** *(a) Before. (b) after 3 weeks.*

*Laser-Assisted Liposuction in Face and Body Contouring DOI: http://dx.doi.org/10.5772/intechopen.99145*

**Figure 7.** *(a) Before. (b) after 3 weeks.*
