INTRODUCTION
The body contour surgery is among the most requested surgical procedures in aesthetic
plastic surgery. Since the beginning of body contouring surgery, several authors around
the world described significant advances in technique, with their cultural changes
and scientific developments1.
In 2017, according to data from the International Society of Aesthetic Plastic Surgery
(ISAPS), 1,573,630 liposuction procedures were carried out worldwide, with more than
210,000 procedures performed in Brazil2.
The introduction of lipoplasty into the surgical arsenal by Illouz, in 19853 and 19894, produced many changes in body contouring procedures with the use of white cannulas
with holes for grease suction.
However, in 19935, Mentz was the first to perform a superficial liposuction to define the abdominal
muscles of male patients, which he called abdominal etching. Regarding the treatment
of the superficial layer in specific anatomical regions, this author says in his conclusions
that it would be a technique for specific patients who want to have a muscular abdomen,
with a need for results above the norm.
In 20076, Hoyos and Millard published the association of VASER (Vibration Amplification of
Sound Energy at Resonance Lipo System) with high definition liposculpture. With his
later work, Hoyos, in 20127 and 20188, consolidated the high definition liposuction with concrete results, creating standards
and parameters for its correct performance.
However, it was Scuderi for the first time, in 19879, who popularized the use of continuous ultrasound to produce fat fragmentation in
lipoplasty. The ultrasound, when it is applied internally to the adipose tissue using
a probe or a metal cannula, breaks the cells by three mechanisms: cavitation, thermal
effect, and direct mechanical effect10,11.
Sound Surgical Technologies LLC (Lafayette, CO) developed the VASERTM device, a surgical ultrasound system for the fat emulsion. This system uses solid
probes of small diameter (i.e. 2.9mm and 3.7mm) with grooves around the point to increase
fragmentation and efficiency. The rigid design of the probe redistributes the ultrasound
energy, transferring part of the energy vibration from the point to a region near
the point of the device.
OBJECTIVE
Therefore, the objective of the present study is to present our casuistry and body
contouring experience with the aid of the VASER equipment.
METHODS
The study took place in 2 surgical centers in Florianópolis/SC, from November 2018
to March 2019.
As of November 2018, 50 patients with an indication for body liposuction underwent
the procedure with the help of a third-generation ultrasound equipment (VASERTM).
The surgeries were performed by the same medical team, in different locations, using
a standardized procedure sequence. During the postoperative visits, the photos of
the evolution were taken, as well as the anamnesis and the physical examination for
complications.
All patients signed the surgical consent form. This study was conducted following
the Helsinki declaration.
Surgical technique
The preoperative marks of the liposuction areas were made with the patients in the
orthostatic position. The muscular region is better defined with the active contraction
performed by the patient. The authors use topographic marking in an attempt to present
the places of highest projection and the presence of subcutaneous tissue. The topographic
lines reinforce the places of greatest need for liposuction in the recumbent patient.
For infiltration, a super-wet anesthetic solution was prepared with lidocaine (2%)
and adrenaline (1: 1,000,000). Due to the need for a humid environment to use the
VASERTM, 4 liters of solution are prepared. The cutaneous opening points for the technique
do not differ from the opening sites for classic liposuction; there is no need to
enlarge the incision. The surgical irrigator (FagaTM) is used to infiltrate the super-wet anesthetic solution, in an attempt to compensate
for the additional time generated by the use of ultrasound equipment.
The surgeon determined the selection of the VASERTM probe, the amplitude, and the pulse mode versus the continuous mode, according to
the characteristics of the patient’s localized fatty deposits, which were individualized
by physical examination. In the places where the equipment was introduced, a skin
protector was used in an attempt to avoid skin damage by friction or thermal action
of the device.
The protocol of the equipment employs the following parameters of the ultrasound of
the third generation: for abdomen, 70% and time of use of 12 minutes; for the back,
70% and time of use of 12 minutes; y, for arms, 50% y time of use of 4 minutes. The
additional time generated by using the device is approximately 30 minutes. The movement
performed with the VASERTM tip is smooth and continuous, a movement very similar to that performed with the
liposuction cannula.
Initially, the VASERTM is applied in a superficial fat plane, in an attempt to produce anatomical drawings
of body structures, in women: mid/white line, semi-lunar lines and inguinal line.
In the semi-lunar lines, we must mark the meeting point with the rib cage, where we
will liposuction more superficially in an attempt to create local fatty depression.
In men, in addition to the markings mentioned above, we can produce the design of
the metamers of the rectus abdominis muscle. After covering the fatty superficial
plane with the ultrasonic equipment, it is carried out in the entire area of deep
liposuction. Only after completing the VASER, we start the liposuction of the fat
solution.
The complete treatment (VASERTM + Liposuction) is performed in the initial position of decubitus, for the subsequent
change of decubitus and the continuity of the procedure. Only dorsal and ventral decubitus
is used, with the choice of initial decubitus based on surgical planning, especially
when there is a need to obtain fat for gluteal fat grafting.
After using the VASERTM, it is performed liposuction of the fat solution, with the help of a pneumatic vibration
equipment (VibrolipoTM) associated with the use of continuous aspiration equipment (LipoCoelhoTM). Superficial liposuction (anatomical drawing) is performed first, to complement
the patient’s deep liposuction then.
All patients underwent a PortovacTM drainage placement with orientation for extraction on medical return in 1 week.
A local bandage was applied, and the patient remained with a compression mesh associated
with 360º abdominal foam for one month after the operation. Lymphatic drainage began
in the first postoperative week.
RESULTS
During the period between November 2018 and March 2019, 50 patients with a surgical
indication underwent body contour liposuction using third-generation VASERTM technology.
Of this universe of patients, 96% were women (47), with patients with an average age
of 35 years (21-54).
Among the associated procedures we had: 29 of gluteal fat grafting (58%), 24 of abdominoplasty
(48%), 14 of mastopexy with prostheses (28%), 10 of augmentation prostheses (20%)
and 6 of mastopexy without prosthesis (12%). For gluteal fat grafting, we performed
it at the subcutaneous level, with the use of liposuction fat from where VASERTM was used.
The average postoperative drainage explained by PortovacTM was 300 ml/day, with drainage elimination in 1 week (2 liters average in one week).
We present patients photos for the comparison of pre and postoperative (Figures 1 to 5).
Figure 1 - Female patient, 25 years old. A. Preoperative; B. postoperative liposuction 4 months.
Associated with gluteal fat grafting and breast augmentation.
Figure 1 - Female patient, 25 years old. A. Preoperative; B. postoperative liposuction 4 months.
Associated with gluteal fat grafting and breast augmentation.
Figure 2 - Female patient, 25 years old. A. Preoperative; B. postoperative liposuction 4 months.
Associated with gluteal fat grafting and breast augmentation.
Figure 2 - Female patient, 25 years old. A. Preoperative; B. postoperative liposuction 4 months.
Associated with gluteal fat grafting and breast augmentation.
Figure 3 - Female patient, 25 years old. A. Preoperative; B. postoperative liposuction 4 months.
Associated with augmentation mammoplasty
Figure 3 - Female patient, 25 years old. A. Preoperative; B. postoperative liposuction 4 months.
Associated with augmentation mammoplasty
Figure 4 - Female patient, 38 years old. A. Preoperative; B. postoperative liposuction 4. Associated
with gluteal fat grafting.
Figure 4 - Female patient, 38 years old. A. Preoperative; B. postoperative liposuction 4. Associated
with gluteal fat grafting.
Figure 5 - Male patient, 37 years old. A. Preoperative; B. postoperative liposuction 4 months.
Figure 5 - Male patient, 37 years old. A. Preoperative; B. postoperative liposuction 4 months.
There were no postoperative complications, such as seroma, induration, altered sensitivity,
portal burns, infections, skin necrosis, and dyschromia.
DISCUSSION
The refinement of surgical techniques in search for better results is a trend in plastic
surgery. Numerous published studies contribute to a complete compilation of the vascular
anatomy of the entire abdominal unit and back, providing critical directions for more
advanced techniques12,13.
In liposuction, a relatively recent technique, the search for increasingly safer and
aesthetically pleasing procedures is no different. The most recent publications and
scientific events in plastic surgery have highlighted high definition liposuction
or Lipo HD3,4.
Previous authors6,13 have already discussed and presented their results for VASERTM assisted high definition liposculpture: satisfaction in 84% of patients. There was
a seroma in 6.5% of the cases that were solved with punctures. The use of drains was
standardized for 48 to 72 hours. Of the 306 cases, 3.92% had a loss of definition.
One of the great fears about the use of ultrasound technology for the fragmentation
of adipose tissue would be related to burns and necrosis caused by the energetic heat.
We did not find this complication in our studio. In 20076, Hoyos and Millard, presented in their case series a burn of the liposuction portal
during their learning curve, a complication that no longer appeared after the use
of the portal infiltration associated with the skin protector14. The technology associated with the protocol brought security to the use. In the
study by Danilla et al., in 201915 with 417 operated patients, the most frequent complication was hyperpigmentation
(66%), followed by seroma (30%) and nodular fibrosis (20%), with the complications
being transient in almost all of their entirety.
The work in superficial layers for the abdominal definition has always provoked discussions
in the medical field. The aggression to the dermis can cause serious problems, such
as dyschromia, fibrosis, adhesions, irregularities, retractions, and the dreaded epidermolysis
and necrosis. The use of ultrasound technology in superficial layers is another advantage
of the technique. In these layers, it detaches the most proximal fat from the dermis
and makes the removal safer and less aggressive, with better conservation of the skin
texture. There is a need for less movement of the liposuction cannula, after the use
of VASERTM, to remove the same amount of fat as classic liposuction, causing less mechanical
trauma to the patient’s dermis.
The use of third-generation ultrasound combined with the design of low trauma in cannulas
allows us to achieve better results on the abdominal lateral surface and deep liposuction,
creating a defined waist and lateral skin retraction6.
The use of VASERTM causes a better suction of fat by detaching it from attached tissues, facilitating
its removal with less physical effort by the operator. The subsequent suction causes
less bleeding, which can be checked by the color pattern of the liposuction in the
collector (less blood). By facilitating the extraction of fat, it is possible to remove
a higher amount of fat volume, and, by bleeding less, we can remove larger volumes,
without decreasing the patient’s hematocrit/hemoglobin.
The increase in surgical time for the application of VASERTM is compensated by the decrease in the time required for liposuction associated with
the use of surgical irrigator. Even so, the surgeon must plan to increase his surgical
time with the use of technology, especially when implementing the technique, when
the team’s processes are not well standardized. A large number of associated procedures
in our study indicate that it is possible to optimize the use of technology to the
point that combined surgeries do not exceed the programmed and recommended anesthetic
time.
In the study by Nagy and Vanek, in 201216, the VASERTM-assisted lipoplasty method demonstrated a 53% improvement (17x11) in the retraction
of the skin per cubic centimeter of aspirate removed compared to traditional suction-assisted
lipoplasty and a reduction an average of 26% in blood loss compared to suction-assisted
lipoplasty. Swanson in 201217, questioned the calculation methods of the study by Nagy and Vanek16, which had an N of 20 patients. In his own calculations, Swanson17 indicated that a difference of 6% would need a sample of 199 patients, concluding
that it is a weak study in methodology and with conflicts of interest. Matarasso,
in 201218, also questioned the results of the study by Nagy and Vanek16, noting that the likely great advantage of VASERTM would be to facilitate the removal of fat for the surgeon, especially in those with
some degree of fibrosis due to previous liposuction.
Even with the discussions of quantitative evaluation of the VASERTM cutaneous retraction in liposuction, it is sure that it reduces skin flaccidity in
the postoperative period and, in borderline cases, in which we have to choose a skin
resection (abdominoplasty) or only liposuction, the use of ultrasound technology helps
in deciding for a procedure with less scarring and a pleasant aesthetic result, with
a uniform adherence to deep tissues, especially in young patients. When the procedure
of choice is an abdominoplasty, the use of VASERTM produces less traumatic fat removal from the abdominal flap tissue, decreasing the
chances of complications associated with lipoabdominoplasty19.
In order to assess the quality of fatty liposuction for fat grafting, Duscher et al.,
In 201620,21 and 201722, proved that the use of VASERTM does not impair the viability of the adipocyte derived from the stromal cell, vital
information to increase graft retention. Therefore, all fat grafting performed in
the technique is done with liposuction from the area where the VASERTM was used. The only process we use in the fat solution before grafting is a simple
decanting.
We did not see any difference in graft integration or different fat reabsorption rate
with the use of the technique. The fat grafted has a smaller diameter compared to
the fat coming from a classic liposuction, which theoretically would facilitate its
integration, as pointed out by the study by Eto et al., in 201223, who identified the size of the fatty tissue survival zone after its grafting as
smaller than 300microns, so fat grafts greater than 600microns already have a regeneration
zone and possibly a central necrosis zone.
We always recommend the subcutaneous plane for grafting, with large diameter cannulas,
syringe, and supragluteal portals, thus reducing the chances of complications24,25.
In the postoperative period, we noticed a less traumatic evolution for the patient.
Due to less aggression and less bleeding, we have a recovery with fewer symptoms and
faster return of the patient to work activity.
As the postoperative period progressed, we did not have a patient with post-procedure
weight recovery. However, given the use of a technology that facilitates fat removal,
the possible results with the gain of new adipose tissue will be similar to those
found with classical liposuction. The use of the protocol to create extremely athletic
results, with an aspect of muscular hypertrophy, has its specific indication, being
essential to inform the patient about possible unwanted aesthetic results in case
of a significant weight gain.
CONCLUSION
The association of VASERTM in liposuction is a safe and reproducible technique, with the advantage of improving
the result of liposculpture.
1. Clínica Vivva, Florianópolis, Florianópolis, SC, Brasil.
2. Hospital Universitário, Cirurgia Plástica e Queimados, Florianópolis, SC, Brasil.
Corresponding author:
Caio Pundek Garcia, Av. Osvaldo Reis, 3385, Sala 501 Praia Brava, Itajaí, SC, Brazil. Zip Code: 88306-773
E-mail: caio_pgarcia@hotmail.com
