With the increasing number of patient requests for “mommy makeovers,” the use of laser lipolysis as an adjunct to other cosmetic procedures is also on the rise.
Of particular interest is the increase in laser-assisted liposculpture procedures that are done in the same operative session as other procedures.
The most common combinations are laser-assisted liposculpture and breast augmentation, rhytidectomy, rhinoplasty, and blepharoplasty. I have also seen laser-assisted liposculpture used as an adjunctive aid for mini-abdominoplasty and lower abdominoplasty.
See also “A New Surgical Technology for Facial Rejuvenation” by Richard D. Gentile, MD, MBA, in the November 2008 issue of PSP.
I have been offering laser-assisted liposculpture in my practice for 24 months. At first, my laser system was the 6-watt, 1,064-nm, Nd:YAG singlewavelength SmartLipo laser system by Cynosure. Later, I upgraded the system as increased power output was made available.
The first two upgrades were singlewavelength, 1,064-nm units of 12 watts and, later, 18 watts. More recently, I upgraded to the 32-watt, dual-wave MPX SmartLipo laser system (1,064 nm and 1,320 nm).
In clinical use, I discovered optimal applications for each wattage and system. The main limitations were due to low power output (wattage). As power output increased, the time used per treatment decreased and I was able to treat a wider variety of clinical conditions more easily.
Many of the techniques applicable to liposculpture and liposuction are applicable to laser lipolysis.
|Figure 1. This female, in her mid-50s, complained of jowliness and loss of definition at the lower mandibular border. She desired rapid recovery and minimal incisions. She received laser-assisted neck liposculpture under local anesthesia only, using the 6-watt system.|
Following local anesthetic infiltration of the incision sites, tumescent fluid (consisting of 0.9 NaCl along with plain lidocaine, epinephrine, and sodium bicarbonate) is mixed in specific concentrations and infiltrated according to accepted standards. This provides local anesthesia, tumescence of the tissues in the region to be treated, and subsequent hemostasis.
Although all patients receive local anesthesia in this manner, I supplement it with monitored intravenous conscious sedation where indicated, depending on the extent of the procedure, the patient’s medical history, the clinical evaluation, and the patient’s wishes. Lidocaine doses are below 35 mg/kg, in most cases. In rare cases, I have used maximum lidocaine doses of up to 45 mg/kg.
The 6-watt system has been utilized for the treatment of localized lipodysmorphia with minimal skin-fascial laxity. Although fat removal was not done in several instances, I have seen improved results when performing fat removal in most patients. With preexisting volume deficiency, fat removal was contraindicated.
Fat removal for small areas was accomplished with blunt microcannulae of 2 mm or less attached to 10-ml or 60-ml syringes. Standard liposuction units were used with cannulae of 2 mm to 4 mm for larger or multiple areas.
Depending on the size, volume, and degree of the patient’s skin-fascial laxity, an average of 15,000 to 45,000 joules of energy were administered in each area treated.
Initially, I used a 300-micron fiber for treatment. Most treatments of a single area took 30 to 60 minutes. Areas treated with the 6-watt system include single, localized areas of lipodysmorphia with minimal skin-fascial laxity, as well as an adjunct to a facelift or neck lift.
|Figure 2. This female underwent a laser-assisted facelift/ necklift with CO2 laser resurfacing on her lower eyes, as well as laser-assisted abdominal liposculpture with mini abdominoplasty using the MPX 32-watt system.|
Many patients have requested the treatment of multiple regions in one session rather than in several small regions over several sessions. Conscious sedation with monitoring has been used in the treatment of the majority of these patients, and the maximum volume of fat removal was kept at 5,000 cc or less, according to established guidelines.
SIX-WATT VERSUS HIGH WATTAGE SYSTEMS
Treatment times using the 12-watt system were reduced by approximately 40% to 50% when compared to the 6-watt system, due to the increased power and corresponding increase in energy delivery. In addition, a 600-micron fiber was used with this upgraded unit.
The 18-watt system further reduced treatment times by another 40% to 50%, compared with the 12-watt system. However, even though treatment times were reduced, energy requirements per treatment area remained approximately the same.
Single and multiple body regions were more easily treated in one session. These areas include the forehead; neck liposculpture; upper arms; and areas around the bra line, flanks, abdomen, and upper legs.
Minimal to moderate gynecomastia without ptosis has been treatable with both the 12- and 18-watt systems.
Currently, the MPX dual-wave SmartLipo system is being used in my practice for all laser lipolysis. In the multiplex mode, this laser system combines two wavelengths (1,064 nm and 1,320 nm).
|Figure 3. This female in her early 20s complained of central body lipodysmorphia (abdomen-waist). Laser-assisted liposculpture using the 18-watt system was used. A 5-pound weight gain followed the surgery.|
The 1,064-nm wavelength is activated first. This is broadly absorbed. When compared to the 1,320-nm wavelength, the 1,064- nm wavelength distributes its energy more homogenously into fat.
Next, the 1320-nm wavelength activates. This wavelength has a stronger affinity for water and less scattering into fat, resulting in more energy localized at the laser tip.
At 1,320 nm, the MPX system converts hemoglobin to methemoglobin, increasing the energy absorption of the 1,064- nm system. Small blood vessels surrounding the treated area are coagulated (hemostatic effect). Heating of subdermal collagen bundles stimulates skin tightening.
The MPX comes with a handpiece called SmartSence, which monitors operator hand movement and minimizes the possibility of thermal injury to the tissues. Should the handpiece remain in the same position without movement, modulation of power output-decreasing and ceasing-prevents thermal injury to the tissues until movement is reinitiated. External skin temperature is continuously monitored to further minimize the possibility of thermal damage.
Using this system, average treatment times work out to 15 minutes for the neck, 30 minutes for the flanks, and 60 minutes for the abdomen. Different laser settings and blends are typically used for deep and superficial passes. Only superficial passes are used for neck liposculpture, whereas both deep and superficial passes are used for the abdomen and flanks.
|Figure 4. A female in her late 50s received laser-assisted collagen stimulation and liposhifting using the 18-watt system. Note: no fat was removed.|
The average neck receives 12,000 to 16,000 joules of energy; the average flanks (including both sides) receive 20,000 joules of energy; and the average abdomen receives 90,000 joules of energy.
With the addition of this dual-wavelength unit, my laser liposculpture practice has evolved into treatment of the following general conditions:
- Skin-fascial tightening with volume deficiency;
- Minor recontouring-liposculpture plus skin-fascial laxity; and,
- Extensive lipodysmorphia of a single area or multiple areas of moderate lipodysmorphia and skin-fascial laxity.
Significant volume deficiencies have been seen only in women-usually unmasked by prior liposculpture. Sometimes, these were treatable by “liposhifting” and laser collagen stimulation (without fat removal). Other patients required lipotransfer in addition to the other treatments just mentioned.
I have treated the following regions in female patients:
- Upper arms;
- Upper lateral chest-nearpectoralis muscle insertion;
- Upper and lower back;
- Gluteal region;
- Upper legs; and
- Back of the legs below the gluteal folds.
|Figure 5. A male in his late 30s complained of lipodysmorphia and skin-fascial laxity in his abdomen. He received laser-assisted liposculpture via the 18-watt laser.|
I have treated men in the following regions:
- Forehead, for eyebrow ptosis;
- Flanks; and
Complications encountered using this technology have been minimal and selfcorrecting. However, the main downsides of the SmartLipo technology are the physician’s initial investment in the laser system and the system’s potential for thermal tissue damage.
The potential for complications is minimized by sound surgical judgment along with liposculpture-liposuction training and experience including laser-specific training and instruction.
Robert H. Burke, MD, FACS, DDS, MS, FICS, is the director of The Michigan Center for Cosmetic Surgery in Ann Arbor. He can be reached at (734) 971-0262.