This is the year of fat: fat transfer, fat extraction, fat harvesting. Vendors at the most recent American Society for Laser Medicine and Surgery (ASLMS) conference touted a wide variety of fat-extraction and fat-harvesting devices, all promising to rid bodies of unsightly fat by washing it away, heating it up, melting it, and even freezing it. In some cases, the goal is to reposition the fat elsewhere in the body.
Why is fat removal the darling of aesthetic enhancement? Because no matter what happens in the economy, fat continues to be on the minds and in the bodies of your paying customers.
Perhaps you have a patient who was born with stubborn fat pockets that refuse to disappear no matter how much she diets and exercises. Perhaps your patients are much like the general public: they eat too much, weigh too much, and look for easy and quick-fix solutions to lose the weight.
The statistics speak for themselves. Even though liposuction was down 19% from the past year, it is still in third place among the top five cosmetic procedures performed in 2008. That means 245,000 liposuction procedures were performed in a single year—a lot of fat removal and body contouring.
The exciting news is that the latest technologies can extract and manipulate that fat. To learn more, I interviewed two physicians who have extensive experience with the newest technologies: Daniel Man, MD, who talks about using water-assisted liposuction via the BodyJet device in his practice; and David Kent, MD, who uses laser-assisted lipolysis in the form of the SlimLipo product.
First up is Daniel Man, MD, who is a board-certified plastic surgeon in Boca Raton, Fla. He was a participant in clinical trials for the BodyJet device from Eclipse of Dallas—a technology that was recently made available in the United States for the first time. The technology uses water-assisted liposuction (WAL) to “wash away” fat. He has 4 years of experience using WAL technology and has performed fat removal using this new technique on more than 480 patients.
The “Stand Up” Bed Invention
Daniel Man, MD, performs many of his fat-removal procedures while his patient is standing. This approach allows him to see any irregularities and to see what gravity does to the patient’s body during treatment.
His uniquely designed bed helps the patient stand up at 30°, which gives him a good view of the patient.
The “stand-up” bed allows for less swelling overall, and the patient remains very comfortable—she can breathe more easily than if she was lying down, and she can turn easily from side to side. And at the end of the procedure, she can walk out of the office.
PSP: How do you use this technology to extract and harvest fat?
Man: For fat harvesting, I use an accessory called the AquaShape LipoCollector, which is connected to the BodyJet system. Harvested fat is collected in this container, which is kept in the sterile field. The main advantage of the LipoCollector is the fat is exposed to much less mechanical stress compared to other methods.
Also, due to the gentle method of fat removal using this device, harvested fat is left intact and immediately available for reinjection without the need for costly and time-consuming processing.
The fat is flushed or washed out rather than dissected like regular mechanical methods. That means the less the fat is exposed to air, mechanical distress, or local anesthesia, the more viable it is. Harvested cells are exposed to quite a bit less local anesthetic. That’s important, since evidence in literature suggests that lidocaine is lipotoxic.
With WAL, you don’t infiltrate as much local tumescent; so, as you go in, it puts the tumescent in and sucks out the fat at the same time. The fat is very reinjectable material because the fat cells are very small. They are not clumped together. You don’t need to use centrifuge. The fat is harvested with about 25% liquidity. You don’t need extra time to collect and process the fat because it is isolated in the LipoCollector at the same time as the liposuction procedure.
The sterility is easily maintained because you don’t need to open the container. The container has a special opening at the top where you can extract the top of the collector. The entire system is autoclavable, so there are no fat-collectable disposables you use again.
The BodyJet is gentle on the deep, subcutaneous tissue. You have a lot better control when you are moving the cannula back and forth, and at the same time you are getting the washed-out fat.
|The BodyJet (Eclipse Inc, Dallas)|
WAL selectively separates the fat from the connective tissue, and because it provides just the right amount of pressure in delivering the water jet, it’s sufficient in paralyzing the nerves, [which] causes the blood vessels to contract the blood vessels in the area so there’s less bleeding.
Tumescent fluid is being delivered between the fat cells versus into the fat cells. That’s important, because mechanically it’s then easier to collect those fat cells and suction them out.
You don’t need to use as many drugs even though you use more water. This is because you deliver those drugs with high pressure and efficiency, so that the body is not absorbing as quickly. Whatever you put in comes out, plus the fat, because there’s very little absorption, and the infiltration is constricted to the area you are treating. You are not causing distortion because you are not ballooning the area and causing swelling. That helps give me a good symmetrical result.
I first do infiltration for the local area to be treated and then use 20% of the normal volume. In regular liposuction procedures, you usually use 500 cc. With BodyJet, you put only 75 to 100 cc. You then irrigate and aspirate, and then the third step is drying.
PSP: What are the benefits compared to the traditional lipsosuction methods?
Man: First, there is a lot less risk because you‘re not causing overload of tumescent fluid in the body. There are much better aesthetic results because you’re not distorting the fat. The patient is more comfortable because you can change the pressure level, and it is a much better harvesting method because it’s an all-in-one process. Much faster and smoother results.
The disadvantage of other methods is that you use large-volume infiltration and the drugs stay much longer in the body, and that is not safe. You also have lots of swelling, and then it’s not precise. That leads to more touch-up procedures afterward. Also, with regular tumescent liposuction procedures you are limited to the area where you are working. It is more convenient to work multiple areas simultaneously.
Once you do the suction, you are now ready to inject the patients with their own fat. A patient’s own fat is always the first choice over synthetic fillers since it’s more natural and lasts longer.
I use the fat to build up areas of the face—jawbone, nose, eyebrow, and temples—as well as to improve symmetry over the entire face. It’s very safe and predictable in the face and could be permanent (up to 20 years).
|SlimLipo (Palomar Medical Technologies Inc, Burlington, Mass)|
Skin gets to look better, too, because you nurture your skin with your own fibers, collagen, and your own materials. The human is more receptive to its own materials than foreign matter. My patients actually look younger instantly.
PSP: Do you treat hands?
Man: I inject above the wrist and use a long cannula to insert fat into each finger all the way to the middle. I’m addressing their aging fingers as well as the back of their hands.
PSP: What about scars?
Man: Since I resurface at the same time, the scar becomes less noticeable.
PSP: What about rhinoplasty and the use of WAL technology on other areas of the body?
Man: For rhino, I use a small amount— 1 cc to 2 cc in the dorsum of the nose—and that softens up the entire angular shape of the nose. For buttocks, I remove the portion at the bottom where it’s heavy and reposition it to the top. I typically inject 100 cc to each buttock and keep the remaining fat for future use. My patients have a few days’ downtime and just lay sideways.
For breasts, I use fat as a softening device at the periphery of the breast when reconstructing; or to soften up breast-implant edges so they are not so sharp and are less noticeable.
Then there are the combination therapies. Using the BodyJet fat removal system with fractional skin rejuvenation gives my patients a great result that lasts.
PSP: Who is the perfect candidate for this type of fat removal?
Man: Somebody who has an excess of fat with the right expectations and who is paying attention to a correct diet and exercise. The maximum amount of fat I will extract is 3.5 liters.
|SlimLipo screen and handpiece|
PSP: What complications have you observed?
Man: While all fat-removal technologies come with a possibility for complications, with WAL I have experienced many fewer irregularities—only one case of infection and only one “redo.”
There is a learning curve to this unique procedure. It’s important to be trained by a physician who has done a lot of procedures. I believe you need to perform up to seven cases with someone else before doing these on your own.
PSP: Has the demand for water-assisted liposuction increased or decreased in your practice?
Man: Increased. The demand is up by 70% to 75% over the past 4 years. Now that the BodyJet is FDA-approved, more patients are asking for it.
PSP: How much of your practice revenues are based on fat-related aesthetic procedures?
Man: Thirty percent.
David Kent, MD, of Georgia has a completely different approach for fat removal. Kent, a board-certified dermatologist in Macon, Ga, is by no means new to fat extraction. For 13 years, he has offered his patients tumescent liposuction with the microcannula technique. In 2008, he carefully researched laser-assisted lipolysis and selected the SlimLipo system (from Palomar Medical Technologies, Burlington, Mass), which he now uses in virtually all his cases.
PSP: Please explain the technology you use to extract fat.
Kent: The laser-assisted lipolysis system I use is a selective laser-induced melting procedure—hence, the name Slim. It has the ability to melt fat and tighten skin due to its wavelengths and tip design. SlimLipo is the only system that blends 924-nm and 975-nm wavelengths, which is optimal for absorption by adipocytes.
My technique is as follows: After the usual consultation, full consent, and preoperative photos, the patient arrives and photos are checked and marking is performed. The patient then receives 5 mg to 10 mg of Valium orally.
|Male patient before (left) and after (right) receiving treatments using the BodyJet water-assisted liposuction system.|
Tumescent anesthesia is then placed slowly and meticulously to adequately anesthetize every cubic centimeter. Our maximum lidocaine dose is between 50 mg to 55 mg/kg and is reduced if the patient takes SSRI medications. The patient is then reprepped and draped. Areas to be treated with the SlimLipo laser are marked, and each quadrant marked is approximately the size of my outstretched hand. Access points are made with a 2-mm sterile skin punch and slightly dilated with a micro hemostat. A photo documenting the quadrant pattern and a joule-per-quadrant value is selected based on the patient’s BMI.
All areas are then lased, and the energy is delivered to each section evenly. As the energy is delivered by the laser wand with a to-and-fro, even motion, the effort to pass the wand noticeably decreases to the point that it feels like one is passing a violin bow over a violin effortlessly.
The fat is then aspirated. The fat has a smooth, emulsified appearance, which lets us know the joule quantity is correct. The average joule level per quadrant is 5,000 with a BMI of 25 or greater. With a lower BMI, we deliver less than 5,000 per quadrant.
The total time to perform the procedure is unchanged. It takes approximately 48 to 55 seconds per 1,000 joules of energy to be delivered. The aspiration phase takes noticeably less time as the fat is emulsified.
It is also important to note that the total volumes of fat that are removed are noticeably less than with liposuction without laser lipolysis. Clinical end points for completion of the case are unchanged.
PSP: What are the benefits compared to traditional liposuction methods?
Kent: By having increased absorption in fat, which results in fat melting, there is also contraction of the fibrous septae. This results in vertical as well as horizontal tightening.
The 924-nm wavelength has four times the fat absorption of the 1,064 and the 1,320 wavelengths. The 970-nm wavelength is also absorbed by the water content of collagen in skin, helping to tighten skin.
The SlimLipo tip distributes the energy in a headlight pattern, which allows for optimal fat melting in a zone of lipid liberation. This is in sharp contrast to the 1,064-nm systems, which have tips that only emit energy at the very tip, somewhat like a hot poker.
PSP: Has the demand for fat extraction increased or decreased in your practice?
Kent: After incorporating SlimLipo laser-assisted lipolysis into our practice, our liposuction practice has seen a substantial increase in both consultations and procedures. We have actually had to add additional surgery slots to accommodate patient demand. We are seeing between one and three new consults daily.
Many of our patients have heard from other patients about the even faster recovery, early tightening, and improved results. I have actually seen patients who had consults years before and decided to push back for whatever reason, and then they have returned recently after all these years and scheduled immediately following their consultation.
PSP: How much of your practice revenues are based on fat-related aesthetic procedures?
Kent: In the aesthetic portion of my practice, productivity comes primarily from laser-assisted liposuction and fractional ablative 2940 Erbium resurfacing. We, of course, offer a full array of fillers and Botox therapy, chemical peels, etc.
PSP: How would you characterize your patient satisfaction?
Kent: Patient satisfaction has been extremely high with laser-assisted liposuction. Patients are most impressed with reduced bruising, rapid return to work the first postoperative day, the smooth tight appearance of their result, and not having to have general anesthesia.
Catherine Maley, MBA, is the president of Cosmetic Image Marketing, a firm that specializes in teaching physicians how to attract aesthetic patients to their practice. She can be reached at (877) 339-8833.