Discussion Discussion: Laser Lipolysis: Skin Tightening in Lipoplasty Using a Diode Laser Alan Matarasso, M.D. New York, N.Y.
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he authors’ stated aim of this study was to “investigate skin tightening by laser lipolysis” (SlimLipo; Palomar Medical Technologies, Burlingtion, Mass.), using a dual-wavelength diode laser (924 and 975 nm), with three tip lengths. Their conclusion was that, in these 41 subjects, there was essentially a progressive change in the skin circumference between preoperatively and 90 days postoperatively, that the skin felt and appeared better, and that laser lipolysis caused skin tightening and improvement. They also verified a safe total energy dose of 5 kJ per 10 × 10-cm skin area. Furthermore, the laser caused less blood loss (no percentage amount is reported for an entire case but it is based on photomicrographs) and more adipocyte fragmentation/rupture than what conventional liposuction would cause. Since its inception, liposuction has consistently ranked as one of the more popular aesthetic surgery procedures. Moreover, as the procedure has matured, and almost as long as liposuction has existed, practitioners have searched for a way to simultaneously remove fat and tighten the overlying skin, beginning with subdermal/superficial liposuction to ultrasonic liposuction and now with laser-assisted lipolysis.1–7 In that time, the liposuction marketplace has evolved, medical information is now prolific, and manufacturers recognize the financial possibilities of liposuction and the impact of attaching “laser” to the title, and thus the machinery used for liposuction is now “big business.” All surgeons have witnessed the dramatic results that liposuction alone can produce in reducing circumference in numerous anatomical areas and even in older populations, particularly in “favorable” areas (Fig.1). Consequently, the ideal study with which to measure skin tightening—which, in my opinion would be the From the Manhattan Manhattan Eye, Ear & Throat Hospital. Received for publication November 7, 2014; accepted November 12, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001240
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advantage of the technology reported—is not necessarily the reduction in circumference. Rather, it is a patient serving as his or her own control (e.g., laser lipolysis on one side and conventional liposuction on the opposite side8,9) or possibly performing biopsy on skin that was treated with laser and looking for improvement in the dermal architecture on the lasered site; or perhaps applying the laser to the undersurface of loose skin in the absence of fat removal and demonstrating skin tightening. Parenthetically, similar skin biopsies would also be helpful in validating the claims of skin improvement from fat injections. If proven to be more effective than liposuction alone, laser lipolysis could be another tool for a different aspect of body contouring (just as ultrasonic liposuction is for fibrotic areas) to bridge the gap between fat removal alone and skin excision in notoriously loose skin areas such as the arms or inner thighs,10,11 or to be applied to the skin that remains after excisional surgery to improve the general quality of skin. Therefore, a surgeon might have ultrasonic, traditional, and laser liposuction systems available, depending on what is indicated. When consulting with patients, I routinely use analogies to explain the effect that nonsurgical procedures have on skin tightening. For example, energy systems do not lift skin; rather, they tighten skin, like placing a pair of blue jeans in a hot washing machine or the contraction that ensues when an egg white is placed in a hot frying pan. These effects are not equivalent to excising excess skin, which is akin to hemming long pants. No amount of applied energy currently available will “dramatically” lift or remove skin to the extent that excision would. When examining patients, I also convey to them that every “bulge” that concerns them is a composite of excess skin and fat, and that liposuction removes the fat, essentially relying on the Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
Volume 135, Number 5 • Discussion
Fig. 1. A 59-year-old woman with good skin tone who otherwise might be considered a candidate for "open" surgery. Before and after neck liposuction alone. She also had a four-lid blepharoplasty and large-volume liposuction of the abdomen and flanks. (Above) The patient before the procedure. (Below) The patient after the procedure.
intrinsic ability of the skin to contract. (Invariably, the next question is,“What percentage of the bulge is fat and how much will go away?”) We are currently in the dawn of our ability to treat broader categories of body contour problems and not just the fat component, with modalities that span a gamut of problems from “melting” small volumes of fat, to equipment that may have some skin tightening benefit in conjunction with fat reduction, to the new discipline of bariatric plastic surgery for excision of excess skin.12 As advances are made in body contouring, I believe that they will have the ability to focus on a narrower selection of
disagreeable biological conditions, so that eventually we will be able to tailor the technique (“dialing in the controls”) to specifically address the offending tissue layer such as, for example, more skin tightening or less fat removal as indicated. Evolutionary psychologists inform us that it is human nature to prefer procedures that are noninvasive, nonsurgical, or “mini” that result in short scars. Until the time comes when these techniques and technologies are truly customized to the specific defect, it is important that physicians choose the procedure to fit the patient and not the patient to fit the instrument
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Plastic and Reconstructive Surgery • May 2015 they own. Finally, I do not believe that the laser system used in this report is what confers the ability to perform these liposuction procedures on an outpatient basis or under nongeneral anesthesia, which is routinely done in conventional liposuction. In conclusion, the authors have published a study validating the safety of this particular system and verifying the appropriate cumulative energy necessary. Undoubtedly, over the ensuing years, we will witness the ability to significantly improve skin with energy-based devices. These authors have contributed to the long march in that process. Alan Matarasso, M.D. 1009 Park Avenue New York, N.Y. 10028 [email protected]
PATIENT CONSENT
The patient provided written consent for the use of her images. REFERENCES 1. Gasperoni C, Salgarello M, Emiliozzi P, Gargani G. Subdermal liposuction. Aesthetic Plast Surg. 1990;14:137–142.
2. Gasparotti M. Superficial liposuction: A new application of the technique for aged and flaccid skin. Aesthetic Plast Surg. 1992;16:141–153. 3. Matarasso A. Superficial suction lipectomy: Something old, something new, something borrowed…. Ann Plast Surg. 1995;34:268–272. 4. Kim YH, Cha SM, Naidu S, Hwang WJ. Analysis of postoperative complications for superficial liposuction: A review of 2398 cases. Plast Reconstr Surg. 2011;127:863–871. 5. Prado A, Andrades P, Danilla S, Leniz P, Castillo P, Gaete F. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plast Reconstr Surg. 2006;118:1032–1045. 6. Fakhouri TM, El Tal AK, Abrou AE, Mehregan DA, Barone F. Laser-assisted lipolysis: A review. Dermatol Surg. 2012;38:155–169. 7. Matarasso A, Levine SM. Evidence-based medicine: Liposuction. Plast Reconstr Surg. 2013;132:1697–1705. 8. Nagy MW, Vanek PF Jr. A multicenter, prospective, randomized, single-blind, controlled clinical trial comparing VASER-assisted lipoplasty and suction-assisted lipoplasty. Plast Reconstr Surg. 2012;129:681e–689e. 9. Matarasso A. Discussion: A multicenter, prospective, randomized, single-blind, controlled clinical trial comparing VASER-assisted lipoplasty and suction-assisted lipoplasty. Plast Reconstr Surg. 2012;129:690e–691e. 10. Rohrich RJ, Beran SJ, Kenkel JM. Ultrasound-Assisted Liposuction. St. Louis: Quality Medical; 1998. 11. Matarasso A. Ultrasonic assisted liposuction: Is this new technology for you? Clin Plast Surg. 1999;26:369–375. 12. Afrooz PN, Pozner JN, DiBernardo BE. Noninvasive and minimally invasive techniques in body contouring. Clin Plast Surg. 2014;41:789–804.
FILLER-002
American Society of Plastic Surgeons Mission Statement The mission of the American Society of Plastic Surgeons is to support its members in their efforts to provide the highest quality patient care and maintain professional and ethical standards through education, research, and advocacy of socioeconomic and other professional activities.
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T
he authors’ stated aim of this study was to “investigate skin tightening by laser lipolysis” (SlimLipo; Palomar Medical Technologies, Burlingtion, Mass.), using a dual-wavelength diode laser (924 and 975 nm), with three tip lengths. Their conclusion was that, in these 41 subjects, there was essentially a progressive change in the skin circumference between preoperatively and 90 days postoperatively, that the skin felt and appeared better, and that laser lipolysis caused skin tightening and improvement. They also verified a safe total energy dose of 5 kJ per 10 × 10-cm skin area. Furthermore, the laser caused less blood loss (no percentage amount is reported for an entire case but it is based on photomicrographs) and more adipocyte fragmentation/rupture than what conventional liposuction would cause. Since its inception, liposuction has consistently ranked as one of the more popular aesthetic surgery procedures. Moreover, as the procedure has matured, and almost as long as liposuction has existed, practitioners have searched for a way to simultaneously remove fat and tighten the overlying skin, beginning with subdermal/superficial liposuction to ultrasonic liposuction and now with laser-assisted lipolysis.1–7 In that time, the liposuction marketplace has evolved, medical information is now prolific, and manufacturers recognize the financial possibilities of liposuction and the impact of attaching “laser” to the title, and thus the machinery used for liposuction is now “big business.” All surgeons have witnessed the dramatic results that liposuction alone can produce in reducing circumference in numerous anatomical areas and even in older populations, particularly in “favorable” areas (Fig.1). Consequently, the ideal study with which to measure skin tightening—which, in my opinion would be the From the Manhattan Manhattan Eye, Ear & Throat Hospital. Received for publication November 7, 2014; accepted November 12, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001240
1378
advantage of the technology reported—is not necessarily the reduction in circumference. Rather, it is a patient serving as his or her own control (e.g., laser lipolysis on one side and conventional liposuction on the opposite side8,9) or possibly performing biopsy on skin that was treated with laser and looking for improvement in the dermal architecture on the lasered site; or perhaps applying the laser to the undersurface of loose skin in the absence of fat removal and demonstrating skin tightening. Parenthetically, similar skin biopsies would also be helpful in validating the claims of skin improvement from fat injections. If proven to be more effective than liposuction alone, laser lipolysis could be another tool for a different aspect of body contouring (just as ultrasonic liposuction is for fibrotic areas) to bridge the gap between fat removal alone and skin excision in notoriously loose skin areas such as the arms or inner thighs,10,11 or to be applied to the skin that remains after excisional surgery to improve the general quality of skin. Therefore, a surgeon might have ultrasonic, traditional, and laser liposuction systems available, depending on what is indicated. When consulting with patients, I routinely use analogies to explain the effect that nonsurgical procedures have on skin tightening. For example, energy systems do not lift skin; rather, they tighten skin, like placing a pair of blue jeans in a hot washing machine or the contraction that ensues when an egg white is placed in a hot frying pan. These effects are not equivalent to excising excess skin, which is akin to hemming long pants. No amount of applied energy currently available will “dramatically” lift or remove skin to the extent that excision would. When examining patients, I also convey to them that every “bulge” that concerns them is a composite of excess skin and fat, and that liposuction removes the fat, essentially relying on the Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
Volume 135, Number 5 • Discussion
Fig. 1. A 59-year-old woman with good skin tone who otherwise might be considered a candidate for "open" surgery. Before and after neck liposuction alone. She also had a four-lid blepharoplasty and large-volume liposuction of the abdomen and flanks. (Above) The patient before the procedure. (Below) The patient after the procedure.
intrinsic ability of the skin to contract. (Invariably, the next question is,“What percentage of the bulge is fat and how much will go away?”) We are currently in the dawn of our ability to treat broader categories of body contour problems and not just the fat component, with modalities that span a gamut of problems from “melting” small volumes of fat, to equipment that may have some skin tightening benefit in conjunction with fat reduction, to the new discipline of bariatric plastic surgery for excision of excess skin.12 As advances are made in body contouring, I believe that they will have the ability to focus on a narrower selection of
disagreeable biological conditions, so that eventually we will be able to tailor the technique (“dialing in the controls”) to specifically address the offending tissue layer such as, for example, more skin tightening or less fat removal as indicated. Evolutionary psychologists inform us that it is human nature to prefer procedures that are noninvasive, nonsurgical, or “mini” that result in short scars. Until the time comes when these techniques and technologies are truly customized to the specific defect, it is important that physicians choose the procedure to fit the patient and not the patient to fit the instrument
1379
Plastic and Reconstructive Surgery • May 2015 they own. Finally, I do not believe that the laser system used in this report is what confers the ability to perform these liposuction procedures on an outpatient basis or under nongeneral anesthesia, which is routinely done in conventional liposuction. In conclusion, the authors have published a study validating the safety of this particular system and verifying the appropriate cumulative energy necessary. Undoubtedly, over the ensuing years, we will witness the ability to significantly improve skin with energy-based devices. These authors have contributed to the long march in that process. Alan Matarasso, M.D. 1009 Park Avenue New York, N.Y. 10028 [email protected]
PATIENT CONSENT
The patient provided written consent for the use of her images. REFERENCES 1. Gasperoni C, Salgarello M, Emiliozzi P, Gargani G. Subdermal liposuction. Aesthetic Plast Surg. 1990;14:137–142.
2. Gasparotti M. Superficial liposuction: A new application of the technique for aged and flaccid skin. Aesthetic Plast Surg. 1992;16:141–153. 3. Matarasso A. Superficial suction lipectomy: Something old, something new, something borrowed…. Ann Plast Surg. 1995;34:268–272. 4. Kim YH, Cha SM, Naidu S, Hwang WJ. Analysis of postoperative complications for superficial liposuction: A review of 2398 cases. Plast Reconstr Surg. 2011;127:863–871. 5. Prado A, Andrades P, Danilla S, Leniz P, Castillo P, Gaete F. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plast Reconstr Surg. 2006;118:1032–1045. 6. Fakhouri TM, El Tal AK, Abrou AE, Mehregan DA, Barone F. Laser-assisted lipolysis: A review. Dermatol Surg. 2012;38:155–169. 7. Matarasso A, Levine SM. Evidence-based medicine: Liposuction. Plast Reconstr Surg. 2013;132:1697–1705. 8. Nagy MW, Vanek PF Jr. A multicenter, prospective, randomized, single-blind, controlled clinical trial comparing VASER-assisted lipoplasty and suction-assisted lipoplasty. Plast Reconstr Surg. 2012;129:681e–689e. 9. Matarasso A. Discussion: A multicenter, prospective, randomized, single-blind, controlled clinical trial comparing VASER-assisted lipoplasty and suction-assisted lipoplasty. Plast Reconstr Surg. 2012;129:690e–691e. 10. Rohrich RJ, Beran SJ, Kenkel JM. Ultrasound-Assisted Liposuction. St. Louis: Quality Medical; 1998. 11. Matarasso A. Ultrasonic assisted liposuction: Is this new technology for you? Clin Plast Surg. 1999;26:369–375. 12. Afrooz PN, Pozner JN, DiBernardo BE. Noninvasive and minimally invasive techniques in body contouring. Clin Plast Surg. 2014;41:789–804.
FILLER-002
American Society of Plastic Surgeons Mission Statement The mission of the American Society of Plastic Surgeons is to support its members in their efforts to provide the highest quality patient care and maintain professional and ethical standards through education, research, and advocacy of socioeconomic and other professional activities.
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