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VASER Lipoplasty

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									                                                                                                            plastic surgery




                                                                                                                                            plastic surgery
                                                                                       VASER®
                                                                                         Lipoplasty



B
                                                                                                 By Maurice P. Sherman, M.D.




                                                                                                                                           plastic surgery
Body contouring procedures               efficiency of the probes required                       necrosis or scarring events. Revision
date back to the late 1970s when         high energy settings. The probes                        rates in studies also seemed to be
Europeans such as Georgio Fisher         themselves were large diameter                          reduced by at least 50%.




                                                                                                                                         at t
and others described a selective         with sharp edges, and the hollow




                                                                                                                                               n
localized fat removal procedure using    canulas had insufficient capability of                  ULTRASONIC EMULSIFICATION
suction canulas. Scuderi, in 1987,       aspirating the ultrasonic emulsified                       The idea of ultrasonic
first reported using ultrasonic energy   fat. Due to inefficient distribution of                 emulsification of the fat revolves
for lipoplasty. The first generation     the ultrasonic energy, where most                       around the concept of avulsion versus
of ultrasonic devices was an SMEI        of the energy was directed at the tip                   emulsion. In traditional liposuction,
device, which utilized 4-6mm solid       along with imprecise infiltration of                    surgical skill cannot overcome the
probes. Lysonix, 1996, developed a       tumescent solution, a high rate of                      potential issues associated with the
second generation ultrasonic device      complications was reported in 8-14%                     tearing or avulsion of tissues seen
which had a golf-tee shape at the end    of all procedures. These
of a 5mm canula with a 2mm lumen         complications consisted
for simultaneous aspiration. Finally,    of seroma formation,
                                                                                           The pulse mode lowers the amount of energy
in 2002, a third generation ultrasonic   prolonged indurations, skin
                                                                                           delivered to the target, while maintaining efficiency
device marketed by Sound Surgical        necrosis, hypopigmentation,
Technologies, termed the VASER®          prolonged swelling, and
                                                                                           of emulsification.
System, became available and was         scarring from “end hits”
marketed as LipoSelection®.              producing burns and
                                         cellulitis. This figure contrasts                       with a suction canula. This traumatic
HISTORY OF THE ULTRASOUND METHOD         markedly with a 2% overall                              avulsion technique is caused when
   The early ultrasonic systems          complication rate with VASER                            the fat is introduced into the lumen of
were less than optimal. The low          lipoplasty, with elimination of skin                    the canula, and then sheared off by



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                  the movement of the canula back and       for fat. Nerves, blood vessels, and              target, while maintaining efficiency
plastic surgery

                  forth.                                    connective tissue remain relatively              of emulsification. The VASER
                     This action produces non-selective     undisturbed, promoting smoothness                platform includes a precision fluid
                  tissue trauma, leading to unevenness      of contouring with precise sculpturing           management system, which integrates
                  of fat removal with inconsistent          and contouring finesse. Strain and               infusion and suction, and permits
                  precision and potentially uneven          fatigue on the surgeon during the                accurate measurement of tumescent
                  results. This technique is associated     removal process is significantly eased;          infiltration by plus or minus 1cc.
                  with more painful recovery along with     and because of the reduction of
                  elongated recovery time. Physician        tissue trauma, there is low to minimal           VASER TREATMENT
                  position fatigue can limit cases, or      pain development post-operatively.                  After marking the patient in the
                                                                                The VASER (which             traditional manner and standard
                                                                                stands for Vibration         prepping and draping, a wetting
                                                                                Amplification of             infusion consisting of a standard
    By altering the probes, amount of energy utilized, and
                                                                                Sound Energy at              tumescent Klein’s solution is infused
    the continuous VASER versus pulsed modes, any areas                                                      at a ratio of 1.5 - 2cc per every
                                                                                Resonance) features
    of fat collection throughout the body can be treated.                       small diameter, solid        expected cc of fat removal. The
                                                                                probes which require         infusion serves as thermal protection,
                                                                                only a 4mm incision          as well as a medium for delivery of
                  limit time spent on each case; and        for access.                                      the ultrasonic energy and aids in
                  with more tissue trauma, there is an         There is a pulsed and continuous              formation of the emulsion. A10- to
                  inability to control finesse of the fat   ultrasonic mode which is varied                  20-minute wait before ultrasonic
                  removal. This contrasts with emulsion     according to the type of tissue                  application ensures a dry field with
                  seen with delivery of ultrasonic          treated. The pulse mode lowers the               almost total absence of blood in the
                  energy, which is tissue selected          amount of energy delivered to the                aspirate. VASER probes are inserted




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                                                                                                       harm non-fatty tissues. The vents




                                                                                                                                                 plastic surgery
                                                                                                       also prevent clogging of the canula
                                                                                                       and tubing.
                                                                                                          The emulsified fat is collected
                                                                                                       in containers, with the aspirated
                                                                                                       fat showing a significant reduction
                                                                                                       in blood staining compared to
                                                                                                       traditional techniques. Foam
                                                                                                       padding is then applied to the
                                                                                                       treated areas, in addition to an
                                                                                                       elastic compression garment that
                                                                                                       is placed on the patient. Post-
                                                                                                       operative instructions include
                                                                                                       immediate ambulation with full
                     Before (Left) and After Abdomen Treatment (Right).                                activity beginning in 7-10 days. We
                         Photos Courtesy Maurice P. Sherman, M.D.
                                                                                                       remove the foam padding after three
                                                                                                       days but instruct our patients to
through the skin ports which are               2.9mm probe is available for very                       wear compression garments for four
either screwed or sutured to the               fibrous tissue seen in male patients or                 weeks. We also highly suggest use
inside of the incised access sites.            in revision cases. The 2.2mm probes                     of Endermologie Massage Therapy
   The proprietary side grooved                are also available for more precise                     starting three weeks after the
design of the solid probes                     use in delicate areas such as the neck                  surgery, and consisting of eight to ten
redistributes the ultrasonic energy            and face.                                               weekly sessions.
from the tip to the sides and                      Several minutes into the
disburses the energy in a more                 application of the ultrasonic energy,                   ADVANTAGES OF THE VASER
efficient manner. Hence, there is              a creamy fat emulsification will be                     TREATMENT
a 50% less energy requirement                  seen exiting the insertion ports.                          By altering the probes, amount of
compared to previous systems.                  Generally, the VASER usage is                           energy utilized, and the continuous
The canulas are blunt and passed               confined to 1 to 1.5 minutes of usage                   VASER versus pulsed modes, any
through tissues easily with less               per every 100cc of
trauma. For body work, 3.7mm                   tumescent solution
diameter probes are used, and the              infiltrated into a given                   The benefits include better sculpting of tissues, especially
probes come with 1, 2, and 3 rings             area. Emulsification                       of a fibrous nature, faster overall surgical time, significantly
at the distal tip. The 3-ring probe            is followed by                             less work for the surgeon with less bruising and discomfort
produces more disbursement of the              aspiration using a                         for the patient, secondary to the reduced tissue trauma
ultrasonic energy away from the                proprietary Vent                           from evacuation of the fat.
tip, and the 1-ring probe produces             X™ Canula. The
more concentration of the ultrasonic           canula comes in
energy at the tip.                             multiple diameter sizes and is of a
These variations produce probes                non-aggressive design with a blunt                      areas of fat collection throughout
that can be altered specifically for           tip. The handle is vented to provide                    the body can be treated. The main
the amount of fibrous nature of the            continuous uninterrupted suction                        VASER advantages include ease of
treated areas. Additionally, a 3-ring,         without suction surges which may                        fat aspiration, more precise aspiration



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                  and body contouring, easier recovery        reduction techniques provides for a                or wound breakdown. Excellent
plastic surgery

                  secondary to minimal production             definitive noticeable amount of skin               post-operative nipple sensation
                  of pain, discomfort, and bruising.          contraction compared to traditional                has been reported in my patient
                  Perhaps the most significant                liposuction. This quality is especially            experience.
                  advantage in my practice is the             desirable in breast liposuction for
                  ability to produce skin contraction/        reduction. This characteristic also                FACE AND NECK TREATMENTS
                  retraction with use of more superficial     permits simultaneous treatment of                     In the face and neck, the use of
                  application of the ultrasonic energy,       the axillary breast roll seen in many              the small diameter 2.2mm probes
                  which can enable us to utilize the          patients. VASER breast reduction                   combined with the VASER mode for
                  VASER System in place of surgical           is also seen in mastopexy patients                 pulsed application of the ultrasonic
                  resection of excess skin in many            permitting reduction of the breast                 energy allows for the surgeon to
                  situations.                                 mass with minimal bleeding,                        work very close to the dermis in
                                                              and maintenance of the vascular                    thin subcutaneous fatty areas such
                  BREAST REDUCTION TECHNIQUE                  network of the breast tissue, leading              as the neck. Safe contraction of
                     The use of VASER in breast               to reduced incidence of skin necrosis              this tissue is promoted since greater
                                                                                                                 than 50% reduction of applied
                                                                                                                 ultrasonic power is used compared
                                                                                                                 to previous ultrasonic devices. The
                                                                                                                 emulsification also provides the
                                                                                                                 ability to avoid over aggressive use
                                                                                                                 of the suction canula.


                                                                                                                 UPPER ARM TREATMENT
                                                                                                                    In the upper arms, this contraction
                                                                                                                 quality permits VASER liposuction
                                                                                                                 in both the deep and superficial
                                                                                                                 levels to reduce bulk, stimulate skin
                                 Before (Left) and After Abdominoplasty Treatment (Right).                       contraction, and potentially avoid the
                                         Photos Courtesy Maurice P. Sherman, M.D.                                need for brachioplasty. In the lateral
                                                                                                                 back, the surgeon is presented with
                                                                                                                 the challenge of typically fibrous fat
                                                                                                                 with difficult passage of the standard
                                                                                                                 liposuction canula.
                                                                                                                    Because of the ability to switch
                                                                                                                 probes to match tough fibrous tissue
                                                                                                                 type, efficient treatment of both
                                                                                                                 excess fat and redundant skin can
                                                                                                                 be performed, leading to excellent
                                                                                                                 contour shaping without skin
                                                                                                                 resection. For similar reasons, the
                                                                                                                 abdomen also responds favorably
                                   Before (Left) and After Upper Arm Treatment (Right).                          to these qualities and may permit
                                        Photos Courtesy Maurice P. Sherman, M.D.
                                                                                                                 the surgeon to avoid a horizontal



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                                      techniques which produce desirable               months later. In my practice now,




                                                                                                                                      plastic surgery
                                      etching in the abdominal skin                    and for the previous six years,
                                      mimicking the high definition of “two            VASER technology continues to be
                                      packs” or “six packs” seen in male               an indispensable tool in all forms of
                                      and female body builders.                        body lipoplasty.


                                      VASER CLINICAL OUTCOMES
                                         In conclusion, I feel technological
                                                                                                                 Maurice P.
                                      advances seen in the VASER
                                                                                                                 Sherman, M.D.,
                                      Ultrasonic System, along with
                                                                                                                 is a specialist in
                                      education in the optimal use of this
                                                                                                                 Cosmetic, Facial
                                      device, produce excellent clinical
                                                                                                                 Plastic, and
                                      outcomes without the complications
                                                                                                                 Reconstructive
                                      formerly associated with previous
                                                                                                                 Surgery. Dr.
                                      generations of ultrasonic
                                                                                                                 Sherman has
                                      emulsification systems. The benefits
                                                                                        gained a distinguished reputation
                                      include better sculpting of tissues,
                                                                                        as a creator of the “Natural Look” in
                                      especially of a fibrous nature, faster
                                                                                        cosmetic surgery. For the past 19 years,
                                      overall surgical time, significantly
                                                                                        Dr. Sherman has been in private practice
                                      less work for the surgeon with less
                                                                                        both in Vista and La Jolla, Scripps
                                      bruising and discomfort for the
                                                                                        Memorial Hospital campus, and is now
                                      patient, secondary to the reduced
                                                                                        located centrally in Del Mar at the Del
                                      tissue trauma from evacuation of the
                                                                                        Mar Cosmetic Medical Center. Triple
                                      fat. We do not worry about increased
                                                                                        boarded in Cosmetic Surgery, Facial
                                      complication rates and do expect to
                                                                                        Plastic Surgery, and Otolaryngology,
                                      see a significant reproducible degree
                                                                                        he also serves on committees at the
                                      of skin contraction.
                                                                                        San Diego County Medical Society and
                                         Newer modalities such as Laser
                                                                                        is an Associate Clinical Professor of
                                      Lipolysis under the marketed trade
                                                                                        Surgery at UCSD, teaching at Veterans’
                                      labels of “Smart Lipo” and “Cool
                                                                                        Administration Hospital in La Jolla.
                                      Lipo” have emerged over the past
                                                                                        Dr. Sherman has lectured widely since
                                      1-1/2 years based upon their claim
                                                                                        coming to the San Diego area and has
                                      for skin contraction. Whether the
                                                                                        been a faculty member at numerous
                                      VASER or Laser Lipolysis Systems
lower abdominal scar as seen with                                                       national meetings on cosmetic surgery.
                                      produce the same or more skin
abdominoplasty procedures. The                                                          He initiated and donated his services to
                                      contraction is yet to be answered;
pubic mons area also can be treated                                                     the Face To Face Program in San Diego
                                      however, in several antidotal cases
vigorously with the VASER despite                                                       for cosmetic restoration of battered
                                      in my practice where Laser Lipolysis
its typical fibrous nature.                                                             and abused women, and has hosted
                                      and VASER were used in comparable
   Additionally, certain physicians                                                     numerous visiting physicians in his
                                      body areas on the same patient,
such as John Millard, M.D., in                                                          clinic who have observed his surgical
                                      no difference in skin contraction
Colorado have developed high                                                            techniques.
                                      was ascertained in comparing the
definition VASER contouring
                                      post-operative results three to six



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