Peter B. Fodor

Clinical Application of VASER-assisted Lipoplasty: A Pilot Clinical Study

BACKGROUND Although lipoplasty is the most frequently performed aesthetic surgical procedure, ultrasound-assisted lipoplasty (UAL) has not been widely adopted because of its increased potential for complications, complex and bulky instrumentation, additional cost, and steep learning curve. OBJECTIVE We report on the use of the VASER ultrasound device in lipoplasty procedures and compare the clinical outcomes obtained by means of VASER-assisted lipoplasty with those of other UAL devices. METHODS A superwet technique was used, and the wetting solution was uniformly distributed in the intended treatment area. Skin protection measures included use of specially designed skin ports to protect the incision edges and wet towels adjacent to the port locations. Access incisions were 3 to 4 mm in length. The VASER device was used in VASER (pulsed ultrasound) mode by 2 investigators (P.B.F. and M.L.J.); the continuous ultrasound mode was used by these investigators only if tissue emulsification was not readily achieved by using the VASER mode. A third investigator (E.B.d.S.P.) primarily used the continuous mode. Effective fat fragmentation in either mode was achieved by a maximum of 1 minute of treatment time per 100 mL of infused wetting solution. RESULTS In a series of 77 patients treated by 3 different clinicians, satisfactory results were obtained with no major complications. This contrasts with an incidence of complications of 7.9% (median, 4.9%) for first- and second-generation UAL devices as determined by statistical analysis of the literature. CONCLUSIONS The initial clinical experience with VASER-assisted lipoplasty indicates that it is a safe and efficient technique for body-contouring surgery. (Aesthetic Surg J 2002;22:131-146.).

Elevating the Midface with Barbed Polypropylene Sutures

Barbed sutures, either used alone in a closed approach or as part of an open face lift procedure, may be combined with malar implants, soft tissue fillers, chemical peeling, and laser resurfacing. Because cephalad cheek repositioning affects adjacent facial areas, results may include shortening of the lower eyelid distance, flattening of the nasolabial fold, elevation of the submalar tissue, improvement of jowling, and decrease in submalar area fullness.

Breast cancer in a patient with gynecomastia.

A case of breast carcinoma in the midst of florid gynecomastia in a 20-year-old man is reported. Up to now, only two male patients under the age of 21 with breast malignancy have been described in the literature. In contrast, gynecomastia is a more common condition than generally appreciated. The association of gynecomastia, a rather common condition, and cancer of the male breast, a rather uncommon condition, is examined. Mammography is recommended as part of the workup. A new classification of gynecomastia into true, pseudo, and mixed types is suggested. Recommendations for the role of lipoplasty in the treatment of gynecomastia are made.

Suction Mammaplasty: The Use of Suction Lipectomy to Reduce Large Breasts.

Suction lipectomy plays a primary role in the surgical treatment of gynecomastia. It is often the sole modality used to obtain a good result. Lipoplasty, however, has been slow to gain acceptance by the plastic surgical community for the treatment of breast enlargement in women. Illouz was perhaps the first to attempt breast reduction by suction alone. In 1991, Matarasso and Courtiss recommended the procedure for patients who presented preoperatively with an optimal nipple-areola complex position. In 1993, Courtiss recommended a wider application, and by 1998 Gray believed that all patients qualified. In his experience, only 1 of 50 patients who underwent reduction by lipoplasty alone required a subsequent skin-reduction procedure. Kivuls and I reported our respective and parallel experiences in back-to-back papers at the joint 1999 Annual Scientific Meeting of the American Society for Aesthetic Plastic Surgery and the Lipoplasty Society of North America. We agreed that most patients, except those with thin, atrophic skin or with significant glandular ptosis, were good candidates. In this follow-up article, Dr. Matarasso describes how his indications and his technique have changed since his earlier report. Although I concur with Dr. Matarasso’s general observations, I offer the following comments based on my experience with suction mammaplasty. To begin, in simple terms, the fatty component of the female (or male) breast can readily be removed with blunt-tipped cannula lipoplasty. A sharp-tipped instrument can also remove glandular tissue but with difficulty and excessive trauma. In my judgment, its use in breast reduction is unjustified. All patients should obtain a preoperative mammogram. The higher the ratio of fat to glandular tissue, the more the breast can be reduced with suction. To determine this, mammography is the most reliable tool; breast palpation is a poor alternative. To date, the majority of my patients have had at least 40 percent of the breast composed of fatty tissue. Only one patient (a 22-year-old student) was advised, based on mammography, not to undergo suction for breast reduction. A “new baseline” mammogram, no sooner than 6 months postoperatively, is also recommended. The procedure works best for young patients and for primary or postreduction breast asymmetry patients (Fig. 1, above). Older patients, when properly prepared, can also be content with the result. Even when the ptosis correction has been minimal or moderate, many patients have reported feeling “less matronly” (Fig. 1, below). Patients with thin, atrophic skin with stretch marks or significant glandular ptosis are not good candidates for suction mammaplasty. The thicker and more elastic the skin envelope is (most common in younger patients), the greater the postoperative expectation can be for centripetal skin remodeling and elevation of the nipple-areola complex. Measurements of the distance from clavicle to nipple are recorded preoperatively and postoperatively and are documented with photographs displaying

Sideburn reconstruction for postrhytidectomy deformity

A posteriorly based random-pattern scalp flap is described for the correction of sideburn and temporal alopecia. The procedure can be readily incorporated into a coronal lift operation.

Comparative Lipoplasty Analysis of in Vivo-Treated Adipose Tissue.

Traditional lipoplasty, when performed properly, is safe, effective, and well tolerated. It remains the gold standard against which other lipoplasty techniques should be judged. The procedure has, however, been challenged by many “replacement procedures” or “adjunctive techniques” such as laser-assisted lipoplasty, ultrasound-assisted lipoplasty, external ultrasound-assisted lipoplasty, Endermologie, and most recently, power-assisted lipoplasty. Each of these techniques aspires to predictably alter or destroy mature adipocytes while minimizing collateral damage, thereby safely remodeling the subcutaneous fat. Unfortunately, many of these “practice enhancement tools” are adopted before the availability of sufficient scientific information regarding their efficacy and safety. A professional obligation exists for surgeons to determine this information, disseminate it, and understand the role of each technique in lipoplasty surgery. This is likewise true of external ultrasound-assisted lipoplasty. This article is a preliminary but essential step in determining the efficacy of externally applied ultrasound in destroying or altering mature adipocytes, and then by inference remodeling subcutaneous fat tissue. This study originates from the group at University of Texas Southwestern, a leader in attempts to understand ultrasound and apply it to lipoplasty. The authors have begun the difficult task of clinically quantitating adipocyte destruction by examining fat taken from four different areas per patient, each treated by a different methodology, specifically: traditional, ultrasound, and external ultrasound-assisted lipoplasty and external massage (presumably as a negative control). They assert that of the four techniques studied, ultrasound-assisted lipoplasty is the most disruptive technique to adipocyte integrity, whereas external ultrasound-assisted lipoplasty is much less so and is roughly comparable in its destructiveness with external massage. Although this study does perhaps let some of the air from the external ultrasound-assisted lipoplasty balloon, there are several caveats that deserve comment. Despite the honest efforts of the investigators, it is difficult to craft a meaningful scientific methodology for a clinical procedure such as lipoplasty. For example, differences in infiltration volume, timing, and suction technique could all exert confounding influences on the biochemical and pathologic results presented, particularly in a study of only six patients. Furthermore, our experience suggests that tissue sampling and histologic analysis of liposuctioned aspirate are inherently difficult to standardize. Dr. Charles A. Sims, a pathologist at Century City Hospital with whom we have collaborated in previous histologic analyses of fat tissue, has found considerable difficulty in the reliable histologic evaluation of liposuctioned fat aspirate. The authors, however, base their conclusions regarding adipocyte disruption predominantly on the biochemical—not the histologic—evaluation of the extracellular presence of two typically intracellular enzymes, creatinine kinase and glycerol 3-phosphate dehydrogenase. Although these enzymes may be re-

Dr. Fodor's Reply

Dr. Fodors reply: We appreciate Dr. Philip G. Lambruschis comments on our article and his observations regarding the experience with Endermologie® in his practice. The emphasis of our report was on Endermologie® assisted lipoplasty and not on Endermologie® as used without suction. When we first combined it with lipoplasty, this was done with the objective to reduce postoperative surface irregularities, an effect that is very difficult to assess objectively. We sympathize with Dr. Lambruschi and his partners for “a poor investment” they made in being the former owners of “the only free-standing Endermologie® clinic in the …

Preoperative and Postoperative Management of the Body Contour Patient

Rod Rohrich, MD Peter B. Fodor, MD Judith J. Petry, MD, FACS Peter Vash, MD Dr. Rohrich: The first patient (Figure 1) has minimal fat deposits in her hips and thighs and wants liposuction of her lateral thighs. Dr. Fodor, how would you evaluate this patient? Figure 1 Patient has minimal fat deposits in her lips and thighs and wants liposuction of her lateral thighs. Dr. Fodor: This patient appears to be an ideal candidate for lipoplasty. She certainly is not obese, but she has localized fat deposits, and her skin tone is good. As with all of my prospective lipoplasty patients, this patients lifestyle; “aerobic shape”; body weight fluctuations; and intake of vitamins, Chinese herbs, and other remedies would be evaluated preoperatively. A number of potentially harmful nutritional restriction regimens and dietary supplements are currently “in vogue.” Some of my liposuction and face lift patients who had been taking herbs, Chinese medications, and megadoses of vitamins had intraoperative bleeding and postoperative ecchymosis in excess of what one would ordinarily see. So I check medical histories very carefully to make sure patients are not taking any of these medications or large doses of vitamins. Based on these findings, I sometimes postpone surgery until the proper preoperative nutritional balance and aerobic shape are achieved. Dr. Rohrich: Dr. Vash, as an endocrinologist who has vast experience with diet regimens, how do you approach patients like this, who have a minimal amount of generalized fat deposits? Which patients, in terms of their nutrition, diet medications, and weight loss or gain regimens are ideally suited for liposuction? Dr. Vash: First one needs to be certain that the patient does not have a history of any eating disorder, such as bulimia or binge eating. If the patients stable body weight fluctuates by more than 5%, this might …

Influence of suction-assisted lipectomy on coagulation

Suction-assisted lipectomy is the most commonly performed surgical aesthetic procedure in North America today. The procedure is not without significant morbidity, as death as well as serious nonfatal complications have been reported. Thromboembolic disease as a complicating factor of various types of surgical procedures and trauma has been well documented in the literature. Stasis, injury, and hypercoagulation--the limbs of Virchows triad--contribute to predisposition for morbidity. The effects of stasis and injury are experienced with most operative procedures. We questioned whether suction-assisted lipectomy, in the appropriately selected and managed patient, would demonstrate a predisposition toward a hypercoagulable state and subsequent thromboembolic disease. In our group of ten female patients who underwent large-volume liposuction, a carefully selected assay of hematological factors demonstrated alterations consistent with a controlled response to tissue injury, but did not demonstrate a predisposition to a hypercoagulable state or subsequent increased risk of thromboembolic sequelae.

External skin excision in the sebaceous nose and supratip deformity

Some sebaceous noses cannot be properly reduced in size because of redundant skin. After standard rhinoplasty some noses develop a supratip deformity that recurs even after subcutaneous removal of the scar tissue. These noses can be corrected only by wedge-shaped skin excision. Most patients much prefer a pleasantly shaped nose, even at the cost of a midline scar on the nose. Most surgeons are hesitant to add scars to the face. However, the vast experience with wounds following accidents, tumor excisions, or corrections of malformations has shown that generally scar formation on the nose is inconspicuous. Nineteen patients were treated successfully by skin excision at the time of primary rhinoplasty or by a second operation.