Fat Tissue Selective Destruction and Simultaneous Aspiration

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Monica Wiggins
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1 Fat Tissue Selective Destruction and Simultaneous Aspiration Form Compartments for a Flat Skin Result Facial and neck liftings performed to eliminate folds after fat removal close to the undersurface of intact skin having a remarkably flat skin shrinkage as a result, has been a lengthy challenge for plastic surgeons. We introduce a Hollow Microcannula With Simultaneous Aspiration by Pump at Very Low Pressure, using UAL as the method for the selective destruction of the fat tissue and its simultaneous aspiration from facial compartments with the consequent elimination of folds in areas such as jowl, inferior palpebral bags, ROOF, SOOF, nasogenian, submental groove and nasolabial fold. These irregularities start to show after the year-old range, and are generally corrected by the insertion of substances in the fold, which unfortunately fail to vanish them satisfactorily, naturally and permanently. Later in time they become most visible in older individuals because of acute ptosis, and must be treated only by surgery, either as a single procedure o accessory with face liftings, liftings with laser resurfacing, chemical peelings or laser resurfacing. For these procedures the UAL With Simultaneous Aspiration method is ideal because destroys just the fat tissue, preserving the absolute integrity of all other tissue such as nerves, vessels, capillary, lymphatic, connective, elastic fibers, etc. because of their higher density, and causing a minimum or no loss of blood. We started to use UAL in 1990 with the ULTRAVAC with hollow cannula, to follow in 1992 with the SMEI with solid probes and in 1993 using the SURGITRON 3000 with hollow cannulas. In 1994 we finally adopted the ULTRASONIC EMULSIFIER R-94 GMD equipped with titanium hollow cannulas plus an additional low pressure suction pump for the treated tissue simultaneous removal, with around one-thousand successful cases up to this date. This intensive experience allow us to built hollow microcannulas and the light and small instruments capable of delivering the exact ultrasonic frequency to the distal tip of those microcannulas to achieve successful lipolysis in those delicate facial areas such as the jowl and nasogenian surcus. Esthetic facial beauty could be described as a harmonic combination of all face and jowl components, and to perceive such a beauty we depend upon substances in the soft tissue conformed by the skin, its subcutaneous fiber-fatty tissue, the corresponding muscles and the underlying bone structure. 1

2 The skin acquires different characteristics of texture, thickness, elasticity, mobility and pigmentation according to its location in the face, and although its topographic analysis displays several lines, surcus and folds which are different among individuals, we can state they still have several similar features. Consequence of many factors, these characteristics are influenced by age, inheritance, skin thickness, facial musculature and its use habits, plus damages from external harmful effects such solar radiation. The wrinkles or lines originally originate perpendicular to the muscle movement, which further strained by the gravity load, adds to the loss of elasticity in the skin, thus forming folds and bags holding fat tissue. We will describe the most evident surcus, which can be treated by our novel UAL method: 1. External Superciliar 2. Eyebrow 3. Inferior and Superior Residual Palpebral Bags 4. Jowl 5. Nasogenian 6. Nasolabial 7. Subciliar These surcus are intensified by the smile muscle contraction, creating then the cubo-mandibular, the bucal indentation or dimple, and the circumoral, or labial grooves. The nasolabial surcus that up to these days has been one of the most difficult challenges for plastic surgeons, is now just one more procedure in the vast array of face treatments. Starting from the lateral portion of the nasal wing, it proceeds in a curved line laterally arch until it disappear in the oral corner, and as it happens with most facial grooves, it is related with age, because it becomes noticeable at years. The female dermal layer is thinner compared with the male one, because it lacks the means to grow hair, as a consequence of testosterone. Furthermore, in certain face regions the muscle movement must be transmitted directly to the underlying skin, thus making fat tissue removal extremely hazardous for the strong possibility of harming muscle and nerve tissue. With the use of scissors and scalpel in surgery, one must seal the base, and the radiated heat of that indispensable procedure may damage nerves producing paresthesia and often other paralysis. The superlative selectivity of UAL to destroy only the fat tissue eliminates completely this risk in every case of facial fat deposits and their surrounding areas 2

3 METHOD The ultrasound generator is basically an electronic circuit powered by 110/220 VAC, 50/60 Hz, adding an oscillator and amplifier in the circuit, generating high voltage -800 VAC- and frequencies between 21 to 27 khz being conducted to the inverse piezoelectric system enclosed in the handpiece which uses ceramic elements resembling coins with perforated centers separated by metal plates that yield forced polarization. These ceramics contract and expand when electricity of a given frequency is applied to them, producing oscillations according to such frequency, which after bouncing back from a resonator, are transmitted to the hollow cannula, to then move towards its tip. The proximal end is connected to a lowpressure vacuum pump that sucks up simultaneously the now liquefied fat material. These generators are fitted with manual and auto-tuning circuits, which after an initial adjustment, maintain optimal performances at all times. Made from an exact aluminum-vanadium-titanium alloy, the blunt hollow microcannulas used in this method measure 4 cm long, 0.23 cm external diameter with a lumen of 0.11 cm, having a lateral suction slot about 3 cm from the distal end, and a perforation on its tip acting as relief for the lateral suction opening. In contrast to solid probes which make use of the whole ultrasonic power produced, hollow ones as these deliver at their tips a power proportionally reduced according to the thickness of their walls, its bore and external diameter. Therefore they keep cool at all times eliminating burns, but nevertheless being capable of an effective fat destruction. Traveling as alternate sinusoidal waveforms these microwaves must reach the cannula tip at a precise coincidental point, regardless of conditions. The instruments used to power these microcannulas are supplied with auto-tuning circuits, which maintain an optimal performance at all times to achieve this steady oscillation. CAVITATION Cavitation is a physical effect producing bubbles which destroy just fat tissue and occurs "only in aqueous solutions". Pressure alterations going from normal atmospheric values to almost maximum vacuum are produced because of the ultrasound action delivered by the tip of the cannula and in an area of around 0.5 to 1.0 cm from that point, being repeated 21,000-27,000 times per second, or Hertz, according to the unit set frequency. This action reduces the fat tissue boiling point destroying it (lipolysis), because its low density, but 3

4 preserving the absolute integrity of all other tissue, such as nerves, vessels, capillary, lymphatic, connective tissue, elastic fibers, etc. All the way from the area where it was destroyed until reaching the hollow cannula aspirating holes, the adipose material continues to be affected by cavitation, creating the emulsification of part of it, to be finally sucked into the cannula by the negative pressure generated by the low pressure pump. SHRINKAGE AND COLLAPSING The selective fat destruction decreases the septal pressure -whose structure of collagen tissue and elastic fibers is kept intact- with a subsequent and immediate contraction, added to a further tridimentional distribution of the remaining fat tissue. The skin collapses and shrinks immediately, and if we try to fold it or pinch it, we will find out the skin is thoroughly attached, contrary to the conventional or mechanical lipoaspirations, where all septum has disappeared. This contraction is radiated to adjacent areas, causing an inward retraction that collapses the skin, improving its aspect and getting a flat and smooth surface, and a final result resembling a normal loss of weight. THE ACOUSTIC EFFECT In over one year using solid probes at a frequency of 21,000 Hz, and 4 more years with hollow cannulas at about 26,000 Hz, neither the surgeon nor his team have suffered from any hearing loss either temporary or permanent, since the ultrasound is not captured by the human ear. As damage to human audition begins at 140 db and up, we conclude that our equipment is completely harmless to the human ear. THERMAL DAMAGE Paresthesia or hyperthesia is a consequence of cannula friction against the nerve sheaths, which may increase their temperature but without any permanent damage, as they revert within 8-30 days. Hollow cannulas remain cold while being used, and therefore thermal damages are nonexistent. This might explain the absence of any harm to the nerve fibers. Something similar happens to the skin at the entrance incision, with procedures other than lifting accessories, which is necessary to protect. 4

TECHNIQUE Local anesthesia was used in 95% of patients treated, combined with sedation or neurolepto anesthesia.

We use the following modified Klein formula: Saline solution 500 cc Adrenaline Xylocaine with Epinephrine 1:1,000,000 Sodium bicarbonate 0.

The deeper planes are infiltrated first, with gentle back and forth radiated movements, because of their lower resistance to the incoming liquid, and slowing down closer to the surface.

5-1cm incision we proceed to undermine with scissors into the subcutaneous tissue in the direction chosen for the silicone or plastic protector placement, which is fixed to the skin.

5 TECHNIQUE Local anesthesia was used in 95% of patients treated, combined with sedation or neurolepto anesthesia. The remaining 5%, despite being under general anesthesia, were also treated with tumescent infiltration mixed with local anesthesia used always at room temperature. We use the following modified Klein formula: Saline solution 500 cc Adrenaline Xylocaine with Epinephrine 1:1,000,000 Sodium bicarbonate 0.5 cc 25 cc 10 cc The infiltration is started with a 10cc syringe and a 50/8 needle through an incision with a 11 blade, flowing via a 25cm KLEIN needle, by a KLEIN infusing pump set at 5. The deeper planes are infiltrated first, with gentle back and forth radiated movements, because of their lower resistance to the incoming liquid, and slowing down closer to the surface. Once infiltrated, through a 0.5-1cm incision we proceed to undermine with scissors into the subcutaneous tissue in the direction chosen for the silicone or plastic protector placement, which is fixed to the skin. Once the cannula is in place, the ultrasonic unit is turned on, with the suction pump set at ½ atmosphere to avoid tearing the tissues. The deep sub-facial fat tissues are treated first to deal with the greater volumes, to continue later with the superficial layers. Procedures time vary, but we consider a minute for every 5-7 cc of extracted material to be the average. The entrance wound is closed with nylon 5-0, separate sutures. Polyurethane foam and pressure garments are placed over the treated areas for 48 hours. Photo 1: Through the face lift ancillary Procedures Photo 2: Through the mouth Photo 3: Through the skin Photo 4: Nerves and colagen fibres intact 5

6 RESULTS Between July 1997 and March 1999, we have treated 103 patients, (See Chart 1), using the ULTRASONIC MICRO-EMULSIFIER R-97 GMD. In all areas we have obtained a significant reduction of fat volume, with a marked immediate postoperative shrinkage and collapsing of the skin. Procedures were fast, less than 3 minutes for an average 10 cc, with minimal or no blood loss, nor major complications, few lesser complications and fast recoveries. The lipocrite which is always done to evaluate the fat extracted showed oil, small particles of aggregated cells, infiltrating liquid plus cells which have gone through emulsion because of longer time under the ultrasound effect, and just 1% of red cells in its bottom. Furthermore we observed a significant shrinkage and collapsing of the skin in areas surrounding those which had been treated, with best results in the surcus nasogenian and jowl, without any intra or post-operatory depressions and/or alterations of the skin surface. We have not found areas of anesthesia or hypoesthesia, although a 1% of hyperesthesia, which points out the indemnity of the nerve sheaths. In all 103 cases, we did not have any infection for the bateriostatic effect of the cavitation, no need of drainage, and the progress of all treated areas was practically free of fibrous tissue, for the whole integrity was left intact, plus the absence of third places, haematomas and seromas. Minor complications were reduced to skin lesions around the entrance wound (2%), later eliminated by using the protector. Ecchymosis was frequent in treated areas (15%) but was solved by the post-operative use of adhesive foam and elastic garments during 48 hours. CONCLUSION The selective extraction of facial fat tissue with minimal or no complications and fast recoveries has started with the ULTRASONIC MICRO-EMULSIFIER R-97 GMD, with its titanium hollow micro- cannula attached to a hand piece and connected to a low pressure aspirating pump for the simultaneous suction of the liquefied fat tissue. By using ultrasound frequencies together with an inverse piezoelectric transducer, the integrity of higher density tissues is kept intact, while also contributing to the shrinkage and collapsing of the skin, with a flat and smooth surface, minimal lesions and no blood loss because of vessel preservation, and thus avoiding reposition of blood or fluids, and eliminating the maximum limits for removal of large fat tissue volumes. 6

7 The procedure is simple, without stress or effort for the surgeon and team, with average extracted volumes of 5-7 cc per minute without any thermal lesions, keeping the nerve sheaths intact, and the sensitivity of the treated areas unaltered. As an added feature, regardless whether this procedure is done as a lifting complement or not, is the simple and safe way to further undermine the length of the cannula beyond the face portion opened by surgery or away from the entrance orifice, without any risk of damaging nerves or other harder density tissues rather than fat, avoiding the well known major complications. The main objective of this work is to establish certain principles and suggestions on this state-of-the-art technological approach to the lipolysis assisted by ultrasound procedure with titanium hollow micro-cannula and simultaneous aspiration by low pressure pump, with immediate shrinkage and collapsing of the skin, added to fast recoveries without special postoperative care. REFERENCES 1. ROBLES, MF, Personal Communication, USAL Task Force, Nashville, Tennessee, ROBLES, JM, Ultrasonic Lipolysis With Simultaneous Aspiration, Rev.Arg.de Cir.Plast. September 3, STUKEER, F. Plastic and Reconstructive Surgery of the Head and Neck. Proceedings of the Fifth International Symposium. Chapter 35-36, RAMIREZ, O, High-tech face lift. Aesthetic Plat.Surg, 1998, Sept.Oct. 5. TOLEDO, L, Refinements in facial and body contouring Lippincott - Raven 1999, Chapt.22,23 6. MLADICK, RA. Lipoplasty: An ideal adjunctive procedure for face lifting. Clin.Plast.Surg 1989; 16: OWSLEY, JQ Lifting the malar fat pad for correction of prominent nasolabial folds. Plast. Recons.Surg. Vol 91, No. 3, Page 463, March

8 Case 1: Pre and Post after 36 days Case 1: Pre and Post after 36 days Case 2: Pre and Post after 4 days Case 3: Pre and Post after 16 days 8

world [2]. One product of such innovative engineering in is the ultrasound-assisted liposuction

world [2]. One product of such innovative engineering in is the ultrasound-assisted liposuction Taewoo Kim Dr. Ramsey WRIT 340 4/12/2013 Sculpting the Human Body with VASER Ultrasound-Assisted Liposuction Abstract Traditional liposuction methods often involved direct mechanical cutting of the fat