According to the American Society for Aesthetic

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1 INTERNTIONL ONTRIUTION omparative nalysis of lood Loss in Suction-ssisted Lipoplasty and Third-Generation Internal Ultrasound-ssisted Lipoplasty Onelio Garcia, Jr, MD; and Nirmal Nathan ackground: Lipoplasty remains the most common cosmetic surgical procedure performed in the United States. In spite of its well documented clinical advantages, ultrasound-assisted lipoplasty (UL) accounts for less than 20% of all lipoplasty procedures currently performed. Objective: The purpose of this study is to determine the blood content of third-generation internal UL aspirate and compare it to traditional lipoplasty aspirate. Methods: The lipoplasty aspirate of 27 consecutive patients who underwent traditional suction-assisted lipoplasty (SL) of their back and posterior flanks was compared to the aspirate of 30 consecutive patients who underwent third-generation internal UL of their backs and posterior flanks using the VSER Internal Ultrasound Device (Sound Surgical Technologies; Louisville, O). The volume and composition of the wetting solution used was the same for both groups. The aspirate analysis was performed by an independent laboratory on a eckman oulter LH 750 blood analyzer (Fullerton, ) and consisted of complete blood counts after separation of the fat. Results: The hemoglobin content of SL aspirate was 7.5 times greater than in the aspirate. The hematocrit value of SL aspirate was 6.5 times greater than in the VSER-assisted lipoplasty aspirate. Statistical analysis using an independent t test confirmed that the data was statistically significant with P values of <.0001 for both hemoglobin content and hematocrit values. onclusions: We conclude that third-generation internal UL should be considered for patients undergoing large-volume lipoplasty procedures or lipoplasty of tight, fibrous areas, such as the back and posterior flanks, where increased blood loss is expected. (esthetic Surg J 2008;28: ) ccording to the merican Society for esthetic Plastic Surgery, lipoplasty remains the most common cosmetic surgical procedure in the United States, with more than 400,000 procedures performed in In spite of its well documented clinical advantages, 2 8 ultrasound-assisted lipoplasty (UL) is currently performed in only 17.4% of lipoplasty cases. 1 Several factors, such as additional costs, 9 increased surgical time, 2,4,10 technical difficulty with a steep learning curve, 11 greater potential for complications, 2,12 14 and complex machinery and instrumentation certainly play a role in the infrequent use of UL in body contouring. The introduction of third-generation internal ultrasound Dr. Garcia is voluntary ssistant linical Professor, Division of Plastic Surgery, Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL. Mr. Nathan is a research assistant in the same division. devices has addressed many of the drawbacks associated with the early UL devices; however, in spite of the well documented clinical efficiency and safety of the new devices, 5,15 the use of UL has decreased almost 4% since When first introduced in this country, dry lipoplasty was associated with blood loss of 20% to 45% of the volume aspirated. 17,18 The use of epinephrine-containing wetting solutions decreased blood loss to 8% to 30% of the aspirated volume. 18,19 The introduction of the superwet technique, using a 1:1 ratio of infiltrating solution to aspirate, and the tumescent technique, which required up to a 3:1 ratio of infiltrate to aspirate, significantly lowered the blood loss associated with these procedures to a single-digit percentage of the aspirate volume. 20,21 The use of UL further decreased blood loss in the aspirate, 3,22 24 and it has been recently documented that third-generation internal UL yields even a cleaner aspi- 430 Volume 28 Number 4 July/ugust 2008 esthetic Surgery Journal

2 rate, with a higher percentage of supernatant fat. 5,15 The purpose of this study is to document the blood content of third-generation internal UL aspirate and compare it to the blood content of traditional suction-assisted lipoplasty (SL) aspirate. METHODS Twenty-seven consecutive female patients ranging in age from years. to 54.5 years (average age, of 33.3 yrs) underwent SL that included contouring of their back and posterior flanks. The patients in this group had a body mass index (MI) range of 18.8 to 30.1, with an average MI of The volume of wetting solution used was approximately a 1:1 ratio of infiltrate to aspirate and consisted of 1 mg of epinephrine 1:1000/liter of normal saline. There was approximately a 15-minute interval between the infiltration of the wetting solution and the suction phase to allow for the vasoconstriction effects of the epinephrine to take place. Mercedes-type lipoplasty cannulas (3.5 mm and 3 mm) were used, and general anesthesia was used in all cases. The aspirate corresponding to the back and posterior flank lipoplasty was kept separate and sent for analysis. The total volume of aspirate ranged from 1250 ml to 5250 ml (average, 3366 ml). The back and posterior flank portion of the aspirate volume ranged from 450 ml to 1400 ml (average, 768 ml). Thirty consecutive female patients ranging in age from 18.5 years to 70.3 years (average age, 41.9 yrs) underwent third-generation internal UL using the VS- ER device (Sound Surgical Technologies, Louisville, O). The MI range in this group was 19.6 to 33.7 (average MI, 25.6). ll cases included lipoplasty of the back and posterior flanks, and the aspirate corresponding to those anatomic areas was kept separate and sent for analysis. The total volume of aspirate ranged from 1600 ml to 9200 ml (average, 5755 ml). The portion of aspirate volume corresponding to the back and posterior flanks ranged from 800 ml to 4200 ml (average, 2450 ml). For the purposes of this study, the wetting solution used also consisted of 1 mg of epinephrine1:1000/l of normal saline at a 1:1 ratio of infiltrate to aspirate. (We typically use a ratio of 3:1 infiltrating solution to aspirate.) There was also an approximately 15-minute interval following the infiltration of the wetting solution to allow for the vasoconstriction effects to take place. For the purposes of this study, the amplitude setting on the device was 90% continuous VSER mode applied for approximately 1 minute per 100 ml of infiltrating solution used. (Our usual VSER times are approximately 50% to 60% longer). The VSER probes used were mainly 3.7-mm 2- ring and 2.9-mm 3-ring. VentX cannulas (3.7- and 3.0- mm; Sound Surgical Technologies) were used in all of the VSER-assisted lipoplasty (VL) cases. ll cases were performed under general anesthesia. Informed consent was obtained from all patients in both the SL and VL groups. The aspirate from the back and posterior flanks was chosen for analysis because these are tight, fibrous, anatomic areas that are associated with greater blood loss during lipoplasty procedures (Figure 1). The aspirate analysis consisted of complete blood counts after separation of the fat. This was performed by an independent laboratory on a eckman oulter LH 750 blood analyzer (Fullerton, ). Normal values on this analyzer are 12 to 16 gm/dl for hemoglobin and 37% to 47% for hematocrit. ecause the main purpose of the study was to document and compare blood loss in the lipoplasty aspirates, only the hemoglobin and hematocrit values of the complete blood counts were evaluated. Figure 1., Typical bloody suction-assisted lipoplasty aspirate from back and posterior flanks., Typical VSER-assisted lipoplasty aspirate from back and posterior flanks. oth the aspirates are approximately the same volume; however, the VSER-assisted lipoplasty aspirate is typically cleaner and contains a higher percentage of supernatant fat. lood Loss in SL and Third-Generation Internal UL Volume 28 Number 4 July/ugust

3 RESULTS The hematocrit values for the SL aspirate ranged from 2% to 7.2% (mean, 3.98%) compared to the VL aspirate, which had a hematocrit range of 0.3% to 1.1% (mean, 0.61%). The hemoglobin content of the SL aspirate ranged from 1.2 to 3.4 g/dl (mean, 2.23 g/dl). y comparison, the hemoglobin content of the VL aspirate ranged from 0.01 to 0.9 g/dl (mean, 0.3 g/dl). The complete raw data is shown in Table 1. The mean hemoglobin content of SL aspirate was 7.5 times greater than in the VL aspirate. The mean hematocrit value for SL aspirate was 6.5 times higher than in the aspirate from the VL group. VL yielded a more consistent aspirate with significantly less dispersion of both hemoglobin and hematocrit values, as depicted in Figure 2. The data were subjected to an independent t test for statisti- Table 1. Raw data of study group Patient ge (yr) Total aspirate (ml) ack/flank aspirate (ml) Hematocrit (%) Hemoglobin (g/dl) SL VL SL VL SL VL SL VL SL VL Total 90, ,650 20,750 73, Mean Variance SD SL, suction-assisted lipoplasty; SD, standard deviation; VL, VSER-assisted lipoplasty. 432 Volume 28 Number 4 July/ugust 2008 esthetic Surgery Journal

4 Figure 2., Significant differences in hemocrit values between suction-assisted lipoplasty and VSER-assisted lipoplasty., Significant differences in hemoglobin content of the aspirate between suction-assisted lipoplasty and VSER-assisted lipoplasty. Note the consistency of VSER-assisted lipoplasty aspirate and the significant dispersion of values in the suction-assisted lipoplasty aspirate. Figure 3., Preoperative view of a 49-year-old woman., Postoperative view 48 hours after 3100 ml total aspirate was removed by suctionassisted lipoplasty., Postoperative view 60 days after suction-assisted lipoplasty. Figure 4., Preoperative view of a 39-year-old woman., Postoperative view 48 hours after 5250 ml total aspirate removal with suction-assisted lipoplasty., Postoperative view 75 days after suction-assisted lipoplasty. cal significance. The t score for the hematocrit values was and for hemoglobin , with P <.0001 for both hematocrit and hemoglobin, confirming that the data were highly statistically significant. The back and posterior flanks have traditionally been associated with a high degree of ecchymosis in the early postoperative period following traditional lipoplasty (Figures 3 and 4). Digital photography of patients who lood Loss in SL and Third-Generation Internal UL Volume 28 Number 4 July/ugust

5 Figure 5., Preoperative view of a 21-year-old woman., Postoperative view 48 hours after 4250 ml total aspirate was removed by VSERassisted lipoplasty., Postoperative view 60 days after VSER-assisted lipoplasty. Figure 6., Preoperative view of a 29-year-old woman., Postoperative view 48 hours after 6600 ml total aspirate was removed by VSERassisted lipoplasty., Postoperative view 30 days after VSER-assisted lipoplasty. underwent VL of their back and posterior flanks revealed relatively minimal ecchymosis in the early postoperative period (Figures 5 and 6). This substantiates previous similar clinical findings by Jewell et al. 5 and de Souza Pinto et al. 15 None of the patients in this study sustained any VSER-related complications. DISUSSION When all parameters are kept equal, the amount of blood in lipoplasty aspirate is location-dependent in a given patient. Tight, fibrous anatomic areas, such as the back and posterior flanks, are associated with a greater amount of blood loss during lipoplasty procedures than soft areas, such as the lower abdomen or medial thighs. VL was always associated with a cleaner aspirate; however, in the soft areas the blood content of the aspirate was only slightly lower when compared to SL. It is in the posterior flanks and back areas where the significant differences between VL and SL become apparent. Our data, based on aspirate from these anatomic areas, quantitatively confirms previous clinical observations that VL is associated with significantly less blood loss than SL. When using bloody aspirate as the end point before removal of the desired amount of aspirate in posterior trunk lipoplasty, we were able to remove an average of 3.1 times more aspirate from the back and posterior flanks by using VL as compared with SL before the end point was reached. ONLUSION We conclude that VL should be considered for patients undergoing large-volume lipoplasty procedures or lipoplasty of tight, fibrous areas such as the back and posterior flanks where increased blood loss is expected. DISLOSURES The authors have no financial interest in and received no compensation from manufacturers of products mentioned in this article. REFERENES 1. The merican Society for esthetic Plastic Surgery. osmetic Surgery National Data ank, Procedural Statistics, New York: The merican Society for esthetic Plastic Surgery; Volume 28 Number 4 July/ugust 2008 esthetic Surgery Journal

6 2. Rohrich RJ, eran SJ, Kenkel JM, dams Jr WP, DiSpaltro F. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg 1998;101: Fodor P, Watson J. Personal experience with ultrasound-assisted lipoplasty: pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg 1998;101: aker Jr JL. practical guide to ultrasound assisted lipoplasty. lin Plast Surg 1999;26: Jewell ML, Fodor P, de Souza Pinto E, l Shammari M. linical application of VSER-assisted lipoplasty: pilot clinical study. esthetic Surg J 2002;22: Zocchi M. Ultrasonic liposculpturing. esthetic Plast Surg 1992;16: Maxwell GP, Gingrass MK. Ultrasound-assisted lipoplasty: clinical study of 250 consecutive patients. Plast Reconstr Surg 1998;101: Matarasso. Ultrasound-assisted lipoplasty: Is this new technology for you? lin Plast Surg 1999;26: Scuderi N, Paolini G, Grippaudo FR, Tenna S. omparative evaluation of traditional, ultrasonic and pneumatic-assisted lipoplasty: nalysis of local and systemic effects, efficacy and costs of these methods. esthetic Plast Surg 2000;24: Grotting J, eckenstein MS. The solid probe technique in ultrasoundassisted lipoplasty. lin Plast Surg 1999;26: Zukowski M, sh K. Ultrasound-assisted lipoplasty learning curve. esthetic Surg J 1998;18: Rohrich RJ, eran SJ, Kenkel JM. omplications. In: Rohrich RJ, eran SJ, Kenkel JM, eds. Ultrasound-assisted liposuction, 1st ed. St. Louis, MO: Quality Medical Publishing; 1998: Young VL, Schorr MW. Report from the conference on ultrasoundassisted liposuction safety and effects. lin Plast Surg 1999;26: Mladick R. Discussion: Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg 1998;101: de Souza Pinto E, bdala P, Maciel M, dos Santos Fde P, de Souza RP. Liposuction and VSER. lin Plast Surg 2006;33: The merican Society for esthetic Plastic Surgery, osmetic Surgery National Data ank, Procedural Statistics, New York: The merican Society for esthetic Plastic Surgery; Illouz YG. Refinements in the lipoplasty technique. lin Plast Surg 1989;16: Rohrich RJ, eran SJ, Fodor P. The role of subcutaneous infiltration in suction-assisted lipoplasty: review. Plast Reconstr Surg 1997;99: Hetter GP. The effect of low-dose epinephrine on the hematocrit drop following lipolysis. esthetic Plast Surg 1984;8: Fodor P, Watson JP. Wetting solutions in ultrasound-assisted lipoplasty. lin Plast Surg 1999;26: Rohrich RJ, eran SJ, Kenkel JM. nesthetic considerations. In: Rohrich RJ, eran SJ, Kenkel JM, eds. Ultrasound-assisted liposuction, 1st ed. St. Louis, MO: Quality Medical Publishing, 1998: Kloehn R. Liposuction with sonic sculpture : Six years experience with more than 6000 patients. esthetic Surg Q 1996;16: Zocchi ML. Ultrasonic-assisted lipoplasty. lin Plast Surg 1996;23: Scheflan M, Tazi H. Ultrasonically assisted body contouring. esthetic Surg J 1996;16:117. ccepted for publication March 6, Reprint requests: Onelio Garcia, Jr, MD, Merrick Pointe ldg., Suite 102, 3850 ird Road, Miami, FL opyright 2008 by The merican Society for esthetic Plastic Surgery, Inc X/$34.00 doi: /j.asj lood Loss in SL and Third-Generation Internal UL Volume 28 Number 4 July/ugust

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