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INTRODUCTION
Laser lipolysis is a new minimally invasive method for liquefying fat and tightening the skin. The Food and Drug Administration approved the first laser lipolysis device in October 2006 for the surgical incision, excision, vaporization, ablation and coagulation of all soft tissues. Liposuction is an extremely common cosmetic surgical procedure with over 450 000 operations performed in 2007, according to the American Society of Aesthetic Plastic Surgery. It is also fast becoming a preferred method for facial and neck rejuvenation, given the low operative risk, absence of scarring and fast recovery times. The drawbacks associated with traditional liposuction include increased blood loss, ecchymosis, long recovery time with increased postoperative discomfort, skin laxity as well as pulmonary emboli, seromas and visceral perforations.
Since the inception of a 1064 nm pulsed Nd:YAG laser system (SmartLipo, manufactured by Deka, distributed by Cynosure, Westford, MA) in 2006, several additional devices have been introduced to the market. At the time of this publication, these include additional 1064 nm laser devices (Prolipo® by Sciton, Palo Alto, CA, and Lipolite® by Syneron, Irvine, CA), a 1320 nm laser (CoolLipo® by Cooltouch, Roseville, CA), a 980 nm diode device (Lipotherme® by Osyris, Helemmes, France), and a new combination 1064 nm/1320 nm sequential firing laser (Smartlipo Multiplex® by Cynosure, Westford, MA).
These newer technologies are indicated for laser lipolysis as well as improvement of flaccidity. Laser lipolysis addresses the drawbacks mentioned above: increased blood loss, ecchymosis, long recovery time and skin laxity. It achieves these improvements by creating lipolysis, coagulating small blood vessels and inducing new collagen formation, the end result being reduced adiposity, skin retraction and decreased flaccidity.
EQUIPMENT AND LASER SPECIFICATIONS
The standard laser lipolysis device is a pulsed 1064 nm Nd:YAG system. The pulse width is 150 μs and the repetition rate 40 Hz. The power output goes as high as 18 W. The key features of this technology include the short pulse duration that creates a high peak power and the high repetition rate ( Fig. 12.1 ).
Laser lipolysis utilizes a gradient pulse delivering high peak power. Other laser systems use a gated or standard pulse delivery system that delivers energy over a longer period of time, leading to potential collateral tissue damage. The peak power of laser lipolysis leads to adipocyte rupture without charring of adjacent tissue.
In this procedure, energy is transmitted to the subcutaneous tissue through a 300 or 600 μm fiber. The 300 μm fiber is used for machines with power wattage up to 10 W, whereas the 600 μm fiber is used for 18 W and higher. The fiber is seated in a 1 mm diameter stainless-steel microcannula of variable lengths, depending on the treatment location. The fiber optic is extended 2 mm beyond the end of the cannula and cleaved cleanly prior to operating. A guiding red light, referred to as the ‘He:Ne beam’ (helium and neon), aids the surgeon in precisely visualizing the subcutaneous laser fiber location while operating. A 1.5 mm incision, #11 blade stab or 18-guage needle is enough to introduce the cannula, which is then guided through the fat at various depths, including the subdermal layer.
The exact mechanism of action of lipolysis and collagen stimulation is still under investigation. A proposed theory involves photothermal heating and photomechanical effects that disrupt adipocyte membranes, thereby breaking them into smaller particles that are then removed by suctioning or reabsorbed through the lymphatic system. The localized heating induced by the laser also denatures existing collagen, allowing for the stimulation of new collagen and collagen retraction. In addition to lipolysis and collagen stimulation, the laser also coagulates blood vessels, which, when combined with the hemostatic effects of tumescent anesthesia, leads to marked improvement of ecchymoses, seromas and edema.
INDICATIONS AND CONTRAINDICATIONS
Indications and contraindications are shown in Box 12.1 .
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Small localized areas of unwanted adiposity
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Mild to moderate skin laxity
CONTRAINDICATIONS
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Impaired liver function, hepatitis C, chronic hepatitis B, alcoholic liver disease
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Acute infections
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Current pregnancy or pregnancy within the 3 months prior to surgery
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Allergy to lidocaine or epinephrine
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Thin areas with severe dermatoheliosis with little subcutaneous adipose tissue
Laser lipolysis is a body-contouring technique for relatively healthy individuals. Laser lipolysis should be limited to patients who fall into the American Surgical Association class I, II or, rarely, III ( Box 12.2 ).
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Class I = normal healthy patients
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Class II = mild systemic disease that results in some functional limitation
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Class III = moderate to severe disease, which results in some functional limitation
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Class IV = systemic diseases that pose constant threats to life and are functionally incapacitating
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Class V = moribund and not expected to survive 24 hours with or without surgery.
Physicians should obtain a complete history and physical evaluation, particularly regarding recent pregnancy and weight patterns. The surgeon should also verify baseline laboratory data to evaluate liver function and to test for presence of hepatitis pregnancy, occult infection or blood discrasias.
Prior to surgery, it is important to determine whether the patient is an appropriate candidate for laser lipolysis. The ideal candidate is one who has small, localized areas of adipose tissue and mild-to-moderate skin laxity. Patients who have severe skin laxity with minimal adipose tissue, thin ‘crepy’ skin, prominent submental salivary glands or retrognathia are less ideal candidates with features that may hinder optimal results. Those who demonstrate thin ‘crepy’ skin or severe laxity in the absence of subcutaneous adipose tissue are at an increased risk of thermal burns. These patients are candidates for skin-tightening devices (see Chapter 7 ).
The indications for laser lipolysis as it pertains to facial and neck rejuvenation continue to evolve. Historically, liposculpture of the cervical and submental regions were reserved for younger patients with good skin tone. Now, laser lipolysis alone or combined with suction-assisted lipoplasty provides excellent results for patients in their 50s, 60s and even 70s. Generally, laser lipolysis is indicated for patients who have small unwanted localized areas of adipose tissue and mild-to-moderate skin laxity.
Cervical and submental regions are ideal locations for laser lipolysis for several reasons. As highlighted by Zins et al., numerous authors have noted that neck skin, as opposed to facial skin or skin elsewhere, has a unique ability to contract. This clinical observation, while not entirely understood, has prompted many surgeons to opt for more conservative neck rejuvenation, favoring liposculpture over platysmaplasties and neck lifts. Due to the additional contractile effect produced by the laser, surgeons are now noting dramatic improvement in the postoperative cervicomental angles of their patients.
Additionally, the cervical and submental areas are small and therefore can be easily accessed via few, inconspicuous incisions. Also, the risk of lidocaine toxicity is reduced due to the smaller volumes necessary to achieve adequate anesthesia.
There are no contraindications specific to laser lipolysis when compared to traditional tumescent liposuction. The same considerations with regard to tumescent anesthesia and lidocaine toxicity apply.
PREOPERATIVE HISTORY AND CONSIDERATIONS
The preoperative evaluation also involves obtaining adequate history, physical examination, and laboratory data in order to ensure the suitability of the liposuction candidate. Patients with a preexisting cardiovascular or respiratory condition may require medical clearance by their primary-care physicians, cardiologist or pneumonologist. Naturally, patients may downplay the severity of their health conditions for an elective cosmetic procedure.
The physician should be particularly aware of those patients with impaired liver function, hepatitis C, chronic active hepatitis B and alcoholic liver disease because lidocaine is metabolized by the cytochrome P450 enzymes of the liver. While patients with liver disease are at an increased risk of developing lidocaine toxicity, treatment of small areas such as the neck, submental areas and face inherently limit toxicity risk due to the small volumes necessary to achieve adequate anesthesia. Laboratory evaluation should include complete blood count with platelets, serum chemistries, partial thromboplastin time (PTT), prothrombin time (PT), human immunodeficiency virus (HIV), hepatitis B and C panel, and pregnancy test.
A surgical history is also important. Patients with prior surgeries or liposuction may have increased scarring, making passage of the cannula difficult. In these scenarios, one may discuss the prior case with the previous surgeon. The age of scars is also important information to obtain from the patient. Older scars tend to be softer and may be suctioned through, while newer scars should be suctioned around.
Once informed consent is obtained, a baseline patient weight and vital signs are obtained. The weight is used to determine the optimum, safe maximum volume and concentration of tumescent anesthesia. The recommended maximum dose of lidocaine for tumescent anesthesia is 55 mg/kg as per the American Academy of Dermatology. Cardiac monitoring with pulse oximetry and supplemental oxygen should be available and a plan for medical emergencies should be established.
The patient may be photographed using standard lighting and positioning. The patient may be seated or standing, and images should be taken from the front, at 3/4 view and from the side (profile) ( Fig. 12.2 ). It is important to standardize images as much as possible to ensure a correct comparison of before and after images. Excellent clinical photographs are critical because many patients forget their presurgery appearance and are impressed by the change after seeing the before images. Patients are informed that the images are confidential and sign a release if used for research or publication purposes. The images are also vital for medical–legal purposes.
