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Views on Ultrasonic Liposuction 1997: Ultrasonic Liposuction

Source: The American Journal of Cosmetic Surgery

Doctors Boutboul et al. have provided a most interesting and valuable description of the effects of ultrasonic liposuction on the tissues with which the cannula may interact during this procedure: fat, skin, muscle, and vascular structures. These effects are both disturbing (as a destructive effect on "innocent" tissue is documented) and enlightening (parameters required to prevent these destructive effects identified). While preliminary reports suggest the possible superiority of ultrasonic liposuction for treatment of certain patients, the precise role of this technique in the surgeon's armamentarium remains to be fully defined. Certainly, the occurrence of devastating complications in a procedure characterized by a remarkable safety record is worrisome and mandates that each surgeon considering the use of this technique be trained in the proper use of equipment and patient selection.

Of concern is the observation that, as has been the case following the proliferation of other recent technological advances in cosmetic surgery, "reports" of the advantages of ultrasonic liposuction are appearing in the news media prior to publication in peer-reviewed medical journals. Promotions of this sort are unfortunate as the pressures of economic competition tend to encourage surgeons to utilize, perhaps prematurely, such technology prior to definitive elucidation of its advantages and disadvantages via controlled protocols.

Particularly worrisome is my sense that one group involved in the cosmetic surgery " turf battle " appears to be engaging in an attempt to use ultrasonic liposuction as a tool to promote their superiority as practitioners of liposuction>, as situation with which cosmetic surgeons have considerable previous experience. Such anti-competitive efforts are contemptible and usually damage all involved in the turf battle as well as negatively impact the reputation of the procedure itself.

John A. McCurdy, Jr. MD
Honolulu, Hawaii

It is with interest that I read the commentary of Doctor McCurdy from Honolulu, Hawaii concerning my article on ultrasonic lipoplasty.

It seems to me that cosmetic surgeons in the United States are experiencing the same circumstances European cosmetic surgeons experienced in 1992, 1993, and 1994, ultrasound being pushed by influential commercial advertising supported by very few clinical experiences showing no proof of the superiority of ultrasound.

As I reported during the American Academy of Cosmetic Surgery Congress in Palm Springs held from January 16 to January 23, 1997, ultrasound lipoplasty is about disappear. Since the end of 1995 and after treating more than 300 cases, we have stopped using this technique because of many problems and no evidence of clinical superiority over a classic lipoplasty.

Once again, I wish to tell American doctors using the ultrasound technique to be aware of its dangers as well as an absence of progress when compared to simple lipoplaty using micro cannula, tumescent technique, and crossed planes.

Gerard Boutboul, MD
Marseille, France

Dr. Klein 's Views on Ultrasonic Liposuction

Jeff Klein, M.D., wrote an article debunking ultrasonic-assisted liposuction (UAL) in 2000. The following are some quotes from the article.

"Europeans were the first to embrace internal UAL. After an initial period of enthusiasm over internal UAL, it was eventually rejected by the majority of European liposuction surgeons because of an unacceptable incidence of complications. Despite the misgivings of many European surgeons, internal UAL was subsequently introduced into North America. A number of factors have contributed to the initial success of those who have marketed internal UAL in North America. First, there has been a mistaken consumer belief that 'high tech' is synonymous with high quality. Second, because of widespread interest in liposuction, the media is unusually eager to showcase UAL. Third, many surgeons purchased UAL merely because UAL was perceived at 'the cutting edge' of cosmetic surgical technology, and because UAL might attract new patients ?"

"A number of recognized experts have stated that UAL has a 15-70% incidence of seromas?"

"External ultrasonic-assisted liposuction (external UAL) is a sequential process involving the infiltration of tumescent local anesthesia, the percutaneous delivery of ultrasound energy to subcutaneous fat, and finally traditional negative-pressure liposuction...there is no convincing data that external ultrasound provides any clinical benefit."

"Everything about the popularity of UAL in the United States is extraordinary. There is virtually no well-designed comparative clinical research to support UAL. Instead, the driving force for UAL media hyperbole and the public's passion for anything high-tech. Rather than relying on convincing scientific data, may surgeons offer UAL because patients ask for UAL."

"When there is money to be made, entrepreneurs are not reluctant to use deceptive anecdotal information to convince prospective customers of the benefits of a new product. Whenever the person providing information about the safety and efficacy of UAL is also in a position to profit from the successful marketing of UAL, then there is a significant possibility that the profit motive will bias the information."

"An internal UAL cannula inserted through a small skin incision delivers enough acoustic and thermal energy to subcutaneous fat that it can cause widespread damage of blood and lymphocyte vessels, nerves, collagenous stroma, as well as adipocytes. An external UAL paddle applied to skin can readily cause a second-degree burn; when the paddle is applied to skin overlying a bony prominence there is a risk of blistering the periosteum. Clearly, external UAL and internal UAL are not entirely benign..."

"Until proven otherwise it is prudent to suspect that the risk of internal or external ultrasonic-assisted liposuction do not outweigh the purported benefits."

We agree with Dr. Klein!

The American Society for Dermatologic Surgery - Statement on Ultrasonic Liposuction

The following are excerpts only. Find the complete statement in your library.

Tumescent liposuction is currently the standard of care for surgical fat removal. This technique has proven to be effective and safe, and has been employed worldwide by physicians since its development by dermatologic surgeons in the mid 1980s.

Ultrasonic liposuction, originally developed in Italy, was introduced into the United States in 1996. This approach, which involves the use of rapidly vibrating cannulas to liquify fat, was initially proposed as an alternative to tumescent liposuction. The primary drawback of this technology, heat production, dictates that it be performed in a wet environment such as that produced by the tumescent liposuction technique.

Initially, ultrasonic liposuction was promoted as a method that produced better skin retraction and less bleeding than traditional liposuction. To date, there has been no proof that skin retraction is superior after this method. Theoretically, the thermal effects on tissue might induce better contraction of the skin envelope postoperatively. However, aggressive use of this property has led to burns and skin necrois. These complication were reported commonly in Europe during the evolution of this procedure. Other complications of internal ultrasonic liposuction include an increased incidence of lipomas, larger incisions required, and drainage of emulsified fat for 5-7 days postoperatively. The notion that ultrasonic liposuction decreases bleeding is now felt to be due to the necessity that the physician adopt the tumescent technique to perform this procedure. Tumescent liposuction inherently decreases blood loss to a significant degree. Dermatologic surgeons who are experienced in using tumescent liposuction have not noted any difference in bleeding when ultrasonic liposuction is added.

All new technology must be evaluated in terms of its risk-to benefit ratio. In spite of safer second-generation devices, internal ultrasonic liposuction poses a risk to thernal burns and the creation of seromas. External ultrasonic liposuction poses a risk of skin burns. Theoretical concerns about peripheral effects of these devices on internal organs, nerves, and bone have not been proven to date. As of this writing, most physicians employing internal ultrasonic liposuction appear to be using these devices in the initial stages of the procedure. They then finish the case with tumescent liposuction alone. Those employing external ultrasonic liposuction are using it for varying periods of time prior to performing tumescent liposuction. Ultrasonic liposuction has not replaced tumescent liposuction but is being used by some physicians as an adjunctive technique. Some physicians are heavily marketing this new technology while others have rejected it entirely leading to confusion among the lay public.