Four physicians tell PSP about the fat-removal techniques they prefer

Americans want to get rid of their fat. As a result, liposuction is the most common procedure performed in plastic surgeons’ offices today. As the plastic surgery market becomes increasingly saturated, surgeons must find new ways to eliminate the fat from their patients and differentiate themselves from their competitors. Here are four new ap-proaches that differ widely from machine to procedure.

A New Twist on an Old Favorite

Sassan Alavi, MD, is a solo practitioner based at the San Diego Lipo­suction Center. His practice focuses on power-assisted lipo­sculpture.

Plastic Surgery Pro­ducts: How is power-assisted liposculpture different from conventional liposuction?

Alavi: In regular liposuction, a large cannula connected to the liposuction machine goes backward and forward, and can cause considerable pain to the patient. With power-assisted liposuction, the cannula vibrates at 1 mm 70 times per second. The degree of trauma to the tissue is substantially reduced. It’s much less painful and more precise.

PSP: Why do you call it liposculpture?

Alavi: Because we’re really sculpting the body to the desired shape. We’re no longer simply sucking out the fat.

PSP: What are your patients’ reactions to power-assisted liposculpture?

Alavi: Patients are very, very pleased. Most are having a hard time with the areas they’re working on. They’re stuck. They have done what they can with exercise and diet. My patients know that this isn’t weight reduction—it’s really size reduction. That’s why sculpting is an issue here.

With power-assisted liposculpture, I can decrease patients’ sizes and achieve the shapes they want. These are some of our happiest patients.

PSP: What contributes to their happiness?

Alavi: They must have the right expectations. We can get them about 80% of the way to their goals, and they have to do the other 20%. That’s what I tell my patients so that they continue to exercise. These are patients who have been working out for 6 months or 6 years and still can’t get their stomachs flat. But we can flatten the stomach in 1 hour. How could they not be happy with that?

PSP: Besides the abdomen, what are the most common areas you work on?

Alavi: The waist, outer and inner thighs, knees, and back (Figure 1, page 22).

PSP: How will power-assisted liposculpture change the industry?

Alavi: I think it has become an adjunct to exercise and diet. People are now aware that these options are available and are safer with much better results than earlier procedures. After liposculpture, people look good and feel good about themselves. They continue to exercise—or begin an exercise program.

I have several patients who are professional bodybuilders. Before tournaments, we perform some liposculpture to help them get ready.

PSP: How many times have you performed liposculpture?

Alavi: On more than 2,000 patients.

PSP: Do you have any advice for other surgeons?

Alavi: We spend a lot of time with our patients preoperatively. We’re conservative, and we make sure that patients have the right expectations and know the risks and benefits of this procedure. That’s the key. They still need to exercise and to diet—this is no substitute. We can sculpt them only to a certain level—the rest de-pends on how well they take care of their bodies.

Liposuction Plus

Irvin Wiesman, MD, is a double board-certified plastic surgeon at the Anti-Aging Cos­­­metics Institute in Chi­cago. He com­bines traditional liposuction with other techniques and procedures, including endermology.

PSP: Do you have a preferred liposuction method?

Wiesman: In my opinion, there is not a big difference between traditional liposuction and ultrasonic liposuction with respect to recovery, pain, and overall end results. I use the traditional “superwet” technique. This basically consists of infiltrating a solution in an amount equal to the amount of fat I want to aspirate. The solution consists of a numbing medication and a vessel-constricting agent to help with the pain and bleeding, as well as to make fat aspiration easier.

The ultrasound actually causes the fat cells to rupture. I reserve the ultrasound for a “buffalo hump,” the fat deposition on the nape of the neck that is sometimes associated with steroid use or human im­munovirus (HIV).

PSP: Do you see many HIV-positive patients who want liposuction?

Wiesman: In a large urban population, there are a lot. In Chicago, many HIV-positive patients live normal lives and are as concerned with their appearance as anyone else. A component of the anti-HIV medication causes abnormal fat disposition. They want to get rid of that fat.

PSP: How is the rest of your patient base distributed?

Wiesman: I’m finding that many more men than in the past have come into my practice for aesthetic surgery, including liposuction. The most common areas of concern for men are the abdomen and flanks—that’s where they carry most of their fat (Figure 2). This differs from women, in whom the fat is mostly in the hips and the thighs.

PSP: What do you do to help them get rid of the fat?

Wiesman: I take different precautions with men and women because they have different body types. I don’t want to give a woman a masculine silhouette or give a man a woman’s shape. I try to correct dimpling, waviness, and contour irregularities.

PSP: How do you do that?

Wiesman: I’ve been performing additional procedures on my liposuction patients. During the operation, I transfer fat to correct fat irregularities and cellulite. Post­operatively, I send my liposuction patients for endermology.

PSP: Let’s start with the fat transfers. How does that work?

Wiesman: Wherever I aspirate, there is a potential graft. Whatever I take out can be used to correct other areas. The most common cellulite is found around the outer thighs and the buttocks. I break up the fibrous attachments with a “pickle fork” to release the packets and  prevent them from reattaching. This improves the contour. Endermology helps because you’re sharing the skin.

PSP: And how does endermology work?

Wiesman: Endermology is a treatment marketed for cellulite. It’s a machine that sucks in the skin with two rollers that then flatten the skin. I like it be­cause it smoothes out the results, decreases the edema, and improves the patient’s recovery time significantly. I definitely see that the results are better.

PSP: Do you do that on-site?

Wiesman: It’s in a different office in the same suite.

PSP: What are your patients saying about it?

Wiesman: They love it. It feels like a massage. I recommend anywhere from 5 to 10 treatments as soon as the patient stops having significant postoperative pain. It really made a difference in the results.

PSP: How did you decide to combine these techniques?

Wiesman: Once I understood what cellulite was and what causes it, it made sense to break up the packets and prevent the adhesions from re-forming. Once I got into practice, I became interested in outer-fat transfer, using body fat as a filler. Surgeons use it in the lips and the face to correct contour irregularities. It has the potential to be permanent.

When you’re performing liposuction, you’re harvesting your graft. The perfect example is a Brazilian buttocks lift. You liposuction around the buttocks, making them look larger and more contoured. You return your “harvest” to the gluteal region to make it look more prominent.

PSP: How many times have you combined these techniques for your patients?

Wiesman: It’s my third year in practice—I’ve probably done around 100.

PSP: How will it change the industry?

Wiesman: Surgeons must be able to incorporate different types of treatment to achieve nice aesthetic results.

PSP: Do you have any advice for other surgeons?

Wiesman: There are always going to be different techniques for achieving the same result. The most important thing is to give patients safe care with a good aesthetic result, while minimizing complications.

Melt the Fat

Rod Rohrich, MD, FACS, is certified by the Ameri­can Board of Plastic Sur­gery and a past president of the Ameri­can Society of Plas­tic Surgeons. He is in private practice at the Tom Landry Sports Center at Baylor Medical Center in Dallas. He has performed liposuction for more than 17 years and currently uses ultrasonic liposuction in his practice.

PSP: What does ultrasonic liposuction do?

Rohrich: It melts the fat using ultrasonic waves. It implodes the fat, then removes it by traditional liposuction. Ultrasonic liposuction decreases postoperative swelling and recovery. It has really revolutionized body-contouring surgery.

PSP: How does melting the fat help, compared with traditional liposuction?

Rohrich: It allows for much more uniform fat removal. That’s the key. The more uniformly you can remove the fat, the better contour you can get—even in more difficult areas such as the back, arms, and male breasts, and in revision liposuction. In the past, fat in these areas was very difficult to remove with regular liposuction.

PSP: Is that why you use it?

Rohrich: I use it because I get better results, shorter recovery times, and greater patient satisfaction. The revision rate for ultrasonic liposuction is 50% to 70% less than that for traditional liposuction, in my experience.

PSP: What are your patients saying about the ultrasonic technique?

Rohrich: My patients are very pleased with the results, and it is the liposuction method of choice in my practice. It provides improved contouring, minimal blood loss, and better results.

PSP: How many ultrasonic procedures have you performed?

Rohrich: I’ve performed this on more than 1,000 patients.

PSP: Do you have any advice for other surgeons?

Rohrich: You have to be trained to use ultrasound-assisted liposuction. Ideally, you should work with someone who’s an expert or someone you know has done a significant number of these procedures. Begin slowly. Work on difficult areas, such as gynecomastia, or redo some patients and go from there. Training abd observing others are critical.

An Alternative to Surgery

Fiona Wright, MD, is an aesthetic dermatologist with the Aesthetic Insti­tute of Plano in Texas. She specializes in alternatives to surgical liposuction.

PSP: What nonsurgical techniques do you find useful?

Wright: We use a commercial triactive vacuum-massage device that combines radio frequency, infrared-wavelength light, and tissue mobilization to provide cellulite re­moval, skin tightening, and contouring. The second component is delivering vitamin supplements to the problem area to help eliminate fat (Figure 3).

PSP: Why would a plastic surgeon use this technique?

Wright: If a patient comes in for a consultation for liposuction, but after hearing about it she doesn’t want the surgery, this could be a good alternative. Some plastic surgeons may also use it for a bit of contouring. Also, if a patient didn’t get enough done and doesn’t want more liposuction, or if there has been liposuction and something was missed, this can help with regard to contouring and fine-tuning. Look at it as an alternative or supplement.

PSP: What’s the advantage of this over liposuction?

Wright: Lipo­suc­tion often can create cellulite, where­­as this won’t. This is good for people who have had liposuction and their cellulite got worse. Another reason is that when the patient gains weight later, she may gain it in other parts of the body because the fat cells are gone. With this procedure, if you gain weight, you gain it back from where it came.

The biggest advantage is the lack of downtime. Some patients can’t take a week off work, or they don’t want people to know they had it done. This is a half-hour procedure in the office, and they’re done with it.

PSP: How does it work?

Wright: There’s a mechanical machine that rolls up and down like an endermology unit. It has intense pulsed light, which will speed up the metabolism of the actual fat cell. Then, the radio frequency softens the fibrous bands and massages and vacuums to enhance lymphatic flow. I then inject supplements into the problem area. This is done over an 8-week course. The two work well together.

PSP: What are your patients saying about it?

Wright: They like it. I always do the consultations myself to ascertain what their expectations are. It’s more an art than an exact science because I’m contouring, so you have to set the expectations right.

People come to me because they don’t want surgery. I’ve done professional athletes and Dallas Cowboys cheerleaders. Appearance matters to them, and the lack of downtime is important. It’s a big issue for people who are traveling all the time or are in the public eye.

PSP: How many procedures have you performed?

Wright: I’ve been doing this for about a year—between 30 and 40 procedures.

PSP: Do you have any advice for plastic surgeons?

Wright: To promise good results, you really need to have your technicians trained well. It’s very technician-dependent. A lot of people call me because they haven’t received results elsewhere. It’s like a good massage: Some people are really good at it, but some are just OK.

Make sure that you’re well trained. With the injectibles, make sure you’re taught by someone who offers accredited training in body contouring, because they are used for a lot of things. Educate yourself, and understand what it is. Understand your patients. If you can understand patients’ expectations, meet those expectations, and don’t oversell the process, then you can do very, very well with it. PSP

Brandi Larsen is a contributing writer for Plastic Surgery Products.

And Now: Noninvasive Liposuction

rvin Wiesman, MD, told PSP about a technique used in Israel that is still in the experimental stages. An external ultrasound machine uses ultrasound adipocyte-lysing technology to liquefy the fat instead of an invasive procedure.

The machine is placed on top of the skin and pulses through the skin. This liquefies the fat and allows the patient’s body to absorb it and dispose of it through the circulatory system. The low-energy beam is strong only at the tip, enabling it to lyse fat cells without affecting the surrounding tissue.

Its upside: It is not invasive and does not even require anesthesia. Patients say it is painless.

Its downside: It is good only for a limited quantity of fat—up to 500 mL of tissue per treatment, about one fourth of the amount of tissue that is normally removed. The patient must return after 1 month for an additional procedure. It is still in clinical trials, but it was approved this summer for use in some countries in Europe and Asia.

“They were showing the machine at a recent surgery conference. It sounds very interesting because it’s not invasive. There’s definitely a market for it,” says Wiesman.