Vortrag Dr. Schikorski in Brüssel

Dr. med. Michael M. Schikorski
Dept. of Surgery, KKH-Elmshorn, Germany,
Senior Consultant : Priv. Doz. Dr. med. Ernst Thies

Second Congress of Aesthetic Medicine and Dermatological and Plastic Surgery

Brussels
Les Pyramides
24, 25 and 26 September 1999

Perhaps the Future of Body Contouring :
The Combined Procedure of UAL and Modified Low Pressure Slow Motion Suction in TLA versus Resection and Rough Suction

(Abstract)

The Combined Procedure is a standardized combination of Ultrasonic Assisted Lipectomy (UAL) and Suction Assisted Lipectomy (SAL). There are some special physical conditions which defines the method of ultrasound Assisted Lipectomy.

There is a difference of the end point of UAL which has to be respected and the estimated aesthetic end point. After the UAL end point is reached you have to continue by conventional liposuction. SAL has not to be performed in the typical rough manner with quick and hard strokes. Due to primary UAL no vacuum as high as 0.9 bar is needed. This will avoid the risks of rough suction and tissue disadvantages of a high vacuum.

If Ultrasound is used to stimulate the shrinking of the skin as Münker describes you can sometimes avoid the resection of the surplus of skin. For skin stimulation there is no increased risk of skin damage by the use of modern ultrasonic devices and non cutting tips of the sonotrodes. Modern devices will not create increased heat due to an absolutely stable oscillator frequenz. On the other hand heat can be produced by iatrogenic mistakes in the kind of working.

For normal aesthetic liposuction up to 4 liters we solely perform the procedure in Tumescent Local Anesthesia (TLA) without a constant tissue irrigation. For TLA we experienced that there is an enormous improvement of the superficial analgesic quality by additional use of Ropivacain-S, a new long lasting local anaesthetic of the amid type. We will give you the formula of our TLA-Plus solution.

We will demonstrate the tools we use for our methods :
1. the SONOCA-Lipo from Söring/Germany
2. our newly designed slow motion cannulas.
Then we will show how to work with this equipment:
1. UAL & modified SAL
2. If necessary Ultrasonic stimulation of the skin

Finally we will demonstrate some clinical cases where we have avoided the resection of the surplus of skin.

Summary :

Due to the non-heating modern ultrasonic dissectors, constant irrigation during aesthetic UAL is not needed up to an estimated amount of 4 liters of fat aspirate. However, irrigation will be necessary in Large Volume and Mega-Liposuction. Ultrasound Assisted Lipectomy is not able to reach the aesthetic end-point of liposuction, so you have to continue conventionally. At last Ultrasonic skin stimulation leads to increased shrinking of the skin, compared with conventional superficial liposuction. The Combined Procedure will possibly take the place of the more risky and less aesthetic resective methods. This also applies for slim people with relaxation of the cutis.
Only reduced suction pressure is needed, and the use of slow motion cannulas will allow a controlled and gentle operation method with very good results more and more often, without the need of skin resection.

 

 

 

 

 

Perhaps the Future of Body Contouring :
The Combined Procedure of UAL and Modified Low Pressure Slow Motion Suction in TLA versus Resection and Rough Suction

(Lecture)

Presidents,
ladies and gentlemen,

different authors have described the perforation of the thorax and the peritoneal space during conventional liposuction in general anesthesia, with lethal outcome in some cases. This is caused by the typical uncontrolled movement with quick and hard strokes in well known conventional liposuction. Increasing risks are well documented with thinner and more elastic cannulas. In addition, this method of working is exhausting for patients treated in tumescent anesthesia as well as for the doctors.

In these conditions we wanted to find a safer method without rapid movements of the cannulas. We think that cannulas are not swords.

We are using a standardized combination of Ultrasonic Assisted Lipectomy (UAL) and Suction Assisted Lipectomy (SAL), which is completely possible with this unit. This combination allows us some special methodical modifications of suction we want to talk about later on.

There are some physical conditions which determine how one works with ultrasound:

1. ultrasonic waves are mechanical longitudinal waves, applied to the fatty tissue by special probes we call sonotrodes.
2. these mechanical waves cause cavitational processes in the liquids of the intracellular and extracellular space. These cavitational processes are highly energetic implosions of micro gas bubbles.
3. An effective number of cavitational processes depend on a large amount of liquid to rise the vapor pressure (Ph): which means for us that it is physically absolutely necessary to infiltrate a sufficient amount of liquid into the operational field. Using the dry technique with Ultrasound Assisted Lipectomy is a medical malpractice !

The infiltrated volume of liquid works as a cooling agent as well as a lubricant. If there is enough fluid modern ultrasonic devices will not create any heat. They will have an absolutely stable oscillatory frequency. And due to this there is no creation of heat in the piezo-electrical transducer of the handpiece which is normally more than 80 % of the tissue transfer of heat.
After a while you have removed a lot of fatty tissue and now you need more and more strokes to get out the same amount of fat. Then the ultrasound will not only destroy fat but also unintentionally effect the connective tissue, vessels and nerves. At this moment you have to change to conventional liposuction. This is the end-point of UAL. Clinically, you will find nearly no more tissue resistance and the body volume will be again of equal measure as before the infiltration. In front of you, there is still a lot more work with conventional liposuction before reaching the esthetical end point of the procedure.

On the other hand one can create severe heat by iatrogenic mistakes.
The first mistake is a wide angulation inside the tissue. This will lock the Sonotrode between the retinacula cutis, which are clearly visible in this picture. They are freed of fat by the process of selective fat destruction with ultrasound. A second mistake is forcing the Sonotrode through the tissue. This causes a higher resistance of the tissue and a changing of the resonance frequency of the transducer results in a creation of heat. To avoid this the Sonotrode has to move freely with strictly axial strokes. This is effortless and rather similar to the playing of a violin. It ensures that no heat is generated.

Going to this picture showing a huge amount of body fat ending in a deep fold we have to discuss whether skin resection is necessary or not. For this operation we need a lot of time. We need prolonged ultrasound application, too.

So, what have we done ? We started with sequential infiltration of TLA-solution in relation to the estimated fat aspirate of 1 : 1 up to 2 : 1. We normally prefer a relation of nearly 2 : 1. Without a longer waiting period we start UAL immediately.
The procedure has to be systematic, because it is far more difficult to remove forgotten islands. Only when performing abdominal etching, and when defining the linea alba in the upper abdomen, must we start with ultrasound application directly at a subdermal level. In all other cases we begin the operation near the fascia. After we have completed the first fan of tunnels in one flat area, we reach the next level towards the skin by applying gentle pressure with the flat hand on the skin. In this way we mostly suck all the layers of fat with ultrasound assistance. It is very easy and you never need a suction pressure of 0.9 bar. 0.3 to 0.4 bar is enough.

After we reach the basic volume before the infiltration and feel nearly no tissue resistance, we change the operational mode and complete the operation by Suction Assisted Lipectomy. Due to primary UAL it is very easy, and our preferred cannulas are designed to move slowly. The only 1.5 mm small suction holes have accurately rounded borders, so they are not aggressive to the tissue. Despite the small size of the suction holes, the total area of the holes is far larger than that of aggressive cannulas. You only need reduced suction pressure and due to this the cannulas will not tear vessels and connective tissue, and will not be blocked. So even if your movements are slower, the cannulas will work effectively. That gives you full control for every moment of your operation, and minimizes the risk of perforation.

Have a look at a typical view of fat aspirate harvested with the combined procedure as we have described it. You can distinguish the harvested fat of UAL, and above it that of SAL, both with a minimum of blood.

As could be seen in the preceding picture, we only left a small subdermal fat pad. In such cases it is necessary to free the skin from the weight of subcutaneous fat. Otherwise the shrinking of the skin is reduced by that weight. In the lower abdomen we stimulated the shrinking of the skin by precise and systematic ultrasound application directly to the skin. For this reason ultrasound is applied with the sonotrode going backwards as is described by Münker.
The first days result shows only an excessive reduced volume, and slack skin. You could not expect immediate shrinking.

After a fortnight we can imagine an enormous improvement of the figure, with good shrinking of the skin. But obviously a swelling of the subcutaneous tissue is visible in the flanks and at the front.

This Photos show the 70 Year old patient on the operation day and after two and four weeks without any further intervention. We are sure that the shrinking effect of the skin will go on for nearly half a year, so you can expect further improvements.
It must be mentioned that other – plastic – surgeons had decided to resect the skin after liposuction. The patient is very happy not to have scars of skin resection, and I am happy that my conviction that one can often avoid cutting the skin, has been justified. This is true even for older people with relaxed skin if the operation is performed with UAL, and safe if the skin stimulation is done with rounded probes.

We perform aesthetic liposuction, up to an estimated amount of 4 liters of fat aspirate solely in tumescent local anesthesia. Larger amounts of fat in my opinion need an additional constant irrigation or infiltration with ringer lactate and general anesthesia.

With TLA following the Klein formula, where we replaced Lidocaine by Prilocaine because it is less toxic, we have had problems with pain sensations of the patients. These events sometimes disturbed the normal and accurate procedure, and endanger the esthetic result.

This year we started with an additional infiltration of Ropivacaine-S, a new and much less toxic long-lasting local anesthetic compared with Bupivacaine. It is an anaesthetic of the amid type. We give a dose of 100 mg / liter TLA. Since then we no longer had problems. If there is a painful sensation, we can go further on with our operation within seconds after a new infiltration of a minimal volume of TLA.

The measured total plasma levels have always been beneath the borderline of neuro- and cardiotoxicity. We never had any signs of intoxication, and all patients were treated as outpatients.Toxic reactions must be expected at plasmatic levels of 7 micrograms / milliliter. Our results were obviously beneath this limit.

Coming gradually to the end I will show you some pictures of a pair of sisters with an enormous weight loss of 50 kg and 80 kg. We had to resect the abdominal skin and made a neo–umbilicoplasty like Illouz.

Both of these sisters had a cosmetic insufficient relaxation of the skin of the upper arms.

Without further comments from me, please have a look at pre- and post-operative pictures of both sisters.We removed only minimal fat but stimulated the skin in these nearly empty sacks of loose skin by applying ultrasound with a backward movement.

Summary

Due to non-heating modern ultrasonic dissectors, constant tissue irrigation during aesthetic liposuction is not needed up to an estimated amount of 4 liters of fat aspirate.

However, irrigation will be necessary in large volume and mega- liposuction if there is an indication for this procedure. I would prefer gastric bending or a gastroplasty.

Ultrasound Assisted Lipectomy is not able to reach the aesthetic end-point of the liposuction procedure. This has to be done with conventional liposuction or less traumatically with modified low pressure slow motion liposuction.

Ultrasound skin stimulation leads to an increased shrinking of the skin, compared with conventional superficial liposuction.

Finally the Combined Procedure will possibly take the place of the more risky and less aesthetic skin resective methods. This also applies to slim people with relaxation of the cutis.

Thank you very much for your attention.