Body Contouring and VASER Technology, the Fourth Dimension

*Ali Juma, Jamil Hayek and Simon Davies*

#### **Abstract**

Body contouring surgery encompasses several facets. However, it is only in the last 15 years that body-sculpting technology has been incorporated in body contouring on a larger scale. This has added further refinements to the aesthetic outcomes of body contouring surgery. Advances in VASER technology meant it has become synonymous with the art of lipo-sculpture, body sculpting and body contouring. When performing body contouring, the first step in liposculpturing the tissues is to emulsify the fat using ultrasound resonance. The emulsified fat is then aspirated with a powerassisted suction device, and in appropriately selected patients, surgically excising the skin excess to achieve the desired results. It is important not to forget the other added bonuses of VASER technology, which includes reduced surgeon's fatigue, enhanced skin retraction and reduced downtime; all being achieved at a high safety margin. Body contouring does not stop at emulsifying fat and aspirating it. Fat transfer in the selected patients has become an integral part of body contouring surgery. This includes patients wishing breast augmentation and buttock augmentation utilising their own fat, thereby reducing any concerns they may have with using silicone-based implants, whilst achieving cosmetically pleasing long-lasting outcomes. Surgical excision where technology cannot overcome skin excess and laxity adds to the aesthetic outcomes in selected cases, thus bringing to fruition the hybrid surgical approach popularised in the twenty-first century. One example of many is incorporating VASER lipo-sculpture with abdominoplasty.

**Keywords:** body contouring, VASER, lipo-sculpture, abdominoplasty, body sculpting, fat transfer, aesthetic outcomes

### **1. Introduction**

Contouring is defined as the action of changing the shape of something [1] (Cambridge English Dictionary). However, in a Plastic Surgeon's eyes, it is the action of forming and shaping new cosmetically pleasing contours of the body or face. In doing so, thus recreating and restoring the desirable anatomical relationships nearest to the golden ratio of beauty yet respecting the racial differences of beauty.

One of the great doyens of Plastic surgery, Ivo Pitanguy defined body contouring surgery as a collection of procedures with the goal of volumetric manipulation of superficial tissue, normally the adipose tissue, with or without removal of skin excess [2].

In our opinion, body contouring is the foundation of recreating beauty by moulding tissues, proportioning contours and removing excess, be it fat and/or skin when applicable. This recreates positive 'spaces' (light reflection) and negative spaces (shadows) when warranted and where desired (**Figure 1**). We must always remember that the patient's realistic goals and aspirations must be an integral part of our plans in achieving the best results.

Although technologies have added to the outcomes in body contouring, it is of profound importance to remember that it is unlikely to replace surgery in entirety and certainly not for the near foreseeable future. However, it will remain a powerful adjunct to surgery raising the bar to achieve consistent good outcomes in body contouring especially when using the hybrid approach.

The expectations of the human body-form appearance in both sexes have changed over the last five decades. This evolution is in continuous flux and in our opinion, is heavily influenced by factors including social media and designs of attire. This adds significant peer pressures to both patient and plastic surgeon alike.

Peer pressure on the surgeon has its drawbacks, but also has its benefits. One such important benefit is driving advances in our speciality in safe surgical techniques and technologies. This spurs on the medical technology companies influenced by market forces to continually respond to the demands of the plastic surgeon based in part on patient's aspirations.

#### **Figure 1.**

*Forty-two-year-old male who had undergone high-definition body sculpting with VASER. The lipoaspirate was 4.4 litres.*

### **2. Technologies in body contouring**

The technology in body contouring continues to evolve. The devices on the market are numerous; however, as the chapter is designated to talk about VASER technology, body contouring and the hybrid approach, hence, we will concentrate our writing on this technology, its role and relationship with surgery in body contouring.

What does VASER stand for? It is an acronym, which stands for 'Vibration Amplification of Sound Energy at Resonance'. Certainly, a scientific mouthful, which practically can be simplified through describing its action in plain English. The ultrasound waves break up and liquefy fat cells making it easier to remove by liposuction at lower pressures with ease and more abundance than with traditional methods. In doing so reducing surgeon's fatigue yet safely achieving consistent aesthetic outcomes, thus popularising this type of body contouring surgery (**Figure 1**).

### **3. The evolution of VASER**

Ultrasound-assisted liposuction (UAL) broke down fat cells to produce an emulsion, leading to a less traumatic aspiration of fat. Unfortunately, early on high incidence of burns, skin necrosis and scarring occurred [3, 4].

The development of hollow probes rather than the earlier solid probes although meant less risks; however, the high energy delivered meant when used near to skin; burns, scarring, waviness and contour irregularities could occur [3, 4].

The first report of clinical application of a third-generation ultrasound liposculpture device, which used pulsed low-power ultrasound and high-efficiency smalldiameter solid titanium probes; VASER liposculpture was reported by Jewell et al. [5]. The energy was much less and the pulsed mode reduced heat generation, thus reducing risks and potential complications.

The advent of VASER meant plastic surgeons elevated liposuction to new highs, and VASER-assisted liposculpture (VAL) became popularised. Alfredo Hoyos embraced this technology from an early stage and pushed the boundaries to new levels [6].

With these advances was born new nomenclature formulated to describe the complexity of the detailed sculpting of the superficial fat and deep fat over muscles and in between muscles VAHDL [7].

#### **4. The evolution of fat transfer**

Fat grafting and lipofilling are synonymous with fat transfer. In this chapter, we will use the term fat transfer, as in our opinion it is more fitting as a descriptive term than either of the other two; however, the words may be used interchangeably.

Fat transfer was first documented in 1889 when omental fat was grafted between the liver and diaphragm to repair a diaphragmatic hernia [8].

In 1892, Neuber et al. described fat taken from the forearm and transferred to fill a volume and contour irregularity of the face caused by a scar with excellent results [9].

In 1895, Czerny et al. transferred fat from a lipoma of the back for breast reconstruction [10].

The first needle and syringe fat transfer was demonstrated by Brunning et al. in 1911 when he injected for the first-time fat subcutaneously in the nose to correct the aesthetic result following rhinoplasty. Brunning was the first to identify that fat resorption meant the results were not sustainable [11].

Refinements of the fat transfer did not occur until 1975 when the Fischers, father and son, developed the modern techniques of liposuction using metal cannulas [12].

Further advancements in liposuction and fat transfer techniques occurred when in 1992 Coleman proposed a new method of harvesting fat, which minimised trauma to adipocytes [13].

In 1993, Klein added the Tumescent technique which made harvesting fat easier and less traumatic to the adipocytes with less blood loss making large volume fat harvesting possible with a higher safety margin; this popularised large volume liposuction [14].

In our opinion, with the advent of safer large volume fat harvesting, it was only natural that the collected fat ought not go to waste, hence paving the way to large volume fat transfer.

#### **5. Fat donor and recipient sites, our experience**

In this chapter, we will consider the donor sites we commonly harvest fat from and the recipient anatomical sites we transfer fat to. In our series the recipient of fat most common anatomical sites included the face, breasts, and buttocks. This parallels what is documented in the world literature [15].

Our choice of fat donors site/s depends on a number of factors including the amount of fat required, the anatomical area we plan to transfer the fat to, and the anatomical location/s where fat is available especially in the thin patient. We must respect that in harvesting the fat; the donor site/s aesthetic outcomes are appropriately proportioned.

Since we started liposculpturing the body's different anatomical sites with Vaser, it has become much easier to make available the amount of fat required to transfer to breasts and buttocks when other less advanced methods fail at worst or at best may not achieve this in one stage. In our experience, this is not so for the face as the volumes required are relatively small and, in most cases, available even with less advanced technology. In the face and in the majority, we tend to use syringe-assisted lipo-aspiration to harvest the fat for transfer.

#### **6. Face contouring**

When transferring fat to the face or anatomical areas of the face, we tend to use submental fat if available (**Figures 2**–**4**), including when performing a facelift. In the case when submental fat is of limited availability, then we use abdominal fat.

In the case of fat transfer to breasts and buttocks, we use the abdomen, lower back and thighs. The thighs are used as a backup unless the preoperative plan included them as a part of body contouring.

In the face and in selected patients, fat transfer can be used as a sole method of facial rejuvenation instead of dermal, Hyaluronic Acid, fillers (**Figure 5**). Fat can also be used an adjunct to face and midface lift surgery, thus adding further refinement to the cosmetic outcomes.

*Body Contouring and VASER Technology, the Fourth Dimension DOI: http://dx.doi.org/10.5772/intechopen.108935*

**Figure 2.** *Twenty-nine-year-old male 7 months following VASER liposuction of neck and 6 cc fat transfer of fat to chin.*

#### **Figure 3.**

*Thirty-four-year-old male 3 weeks following submental and neck liposuction in addition to buccal fat removal. An 8 cc fat transfer to chin was also performed.*

Fat is injected in key areas of the face including the temples, zygomatic area/ cheeks, midface, nasolabial folds, lateral cheeks, pre-jowl sulcus, marionette lines and jawline. The glabella, brows and forehead are also targeted sites for fat transfer in selected patients (**Figure 5**). Our plans when transferring fat into the face or any of its anatomical areas mirror, the techniques we use when injecting hyaluronic acid dermal fillers in the ageing face (**Figures 2**–**4**).

#### **Figure 4.**

*Twenty-eight-year-old female 1 week following neck liposuction, buccal fat removal and 2 cc fat transfer to chin.*

#### **Figure 5.**

*Fifty-one-year-old female 5 months following 24 cc of fat transfer to face.*

When transferring fat to the face, we methodically target the different planes injecting different consistency of fat in the different compartments, both the superficial and deep fat compartments [16], in addition to depositing the fat on the bone when required.

Our non-surgical dermal fillers experience in injecting the face contributed to us pushing the boundaries with our fat transfer techniques further adding to the aesthetic outcomes of our patients.

We developed a simple formula relating to the amount of fat required to be transferred in face rejuvenation. One millilitre (1 cc) of hyaluronic acid filler equates to 2-3 cc of fat irrespective of age or anatomical area.

However, we must keep in mind that fat does not have the same lifting properties as hyaluronic acid and different anatomical areas require different consistency of fat and viscosity. One such example is Nano-fat in the tear trough and lower eyelids area [17]. We use mechanical agitation to obtain this type of fat following its harvest.

In the twenty-first century, we feel that using high-definition ultrasound is likely to be the next step in progression when transferring fat into the face, thus aiding the accurate placement of fat, helping to avoid blood vessels, thus further reducing risks.
