The Aesthetic Guide is part of the Informa Markets Division of Informa PLC

This site is operated by a business or businesses owned by Informa PLC and all copyright resides with them. Informa PLC's registered office is 5 Howick Place, London SW1P 1WG. Registered in England and Wales. Number 8860726.

Kinder, gentler lipo

Article-Kinder, gentler lipo

Key iconKey Points

  • A Germany-based cosmetic surgeon assessed each of four leading liposuction techniques
  • Aesthetic results and underlying tissue trauma are evaluated

Afschin Fatemi, M.D.
Afschin Fatemi, M.D., a cosmetic surgeon from the S-thetic Clinics (in Dusseldorf, Hamburg, Unna and Munich, Germany), compared four leading liposuction surgery techniques in a series of patients: manual or suction-assisted liposuction (SAL), power-assisted liposuction (PAL), ultrasound-assisted liposuction (UAL) and water jet-assisted liposuction (WAL), and assessed the pros and cons of each in terms of cosmetic outcomes. "Some surgeons swear by a specific technique which is most likely in direct relation to the amount of practice they may have with that technique," Dr. Fatemi tells Cosmetic Surgery Times . "The successes of a particular technique increase with the amount of practice a surgeon has with that technique. What can be compared, however, in trying to find out which of these techniques is best, is the aftermath of the procedures under the skin."

ONE SMOOTH HYPOTHESIS "If a certain type of liposuction surgery seems to result in an increased subcutaneous fibrosis, skin contour irregularities, and other adverse events more than other techniques, one might suppose that there is a correlation to this particular type of technique if you look under the skin," explains Dr. Fatemi. "This study shows that optimal results can be achieved by removing the undesired fat and by preserving the septal fibers, as well as vital vasculature in the subcutaneous tissue," he says. "The more connective tissue you have left over following a liposuction procedure, the better the cosmetic result will be in respect to an even contouring," says Dr. Fatemi, who presented his findings at the recent American Academy of Cosmetic Surgery World Congress of Liposuction Surgery in Dubai.

Endoscopic view of septal fibers that remain intact following ultrasound-assisted liposuction. (Photos credit: Afschin Fatemi, M.D.)
In his study, Dr. Fatemi compared the four liposuction techniques using 3- and 4-mm cannulas for each method, if available. He then performed an endoscopy in each liposuction patient and compared the clinical outcome with the subcutaneous tissue damage seen under the skin following each procedure. Via open abdominoplasty, he also compared effects on the tissue after using different cannulas in the same patient. UNDER THE SCOPE According to Dr. Fatemi, because underlying septal fibers serve as a kind of scaffolding for the subcutaneous tissues, as well as providing the vasculature needed for tissue viability, better cosmetic results can be achieved with a "gentler" technique that preserves more septal fibers. Such septal fiber preservation will also help avoid unwanted adverse events like necrosis. In fact, Dr. Fatemi was able to correlate this with what was seen under the skin upon endoscopic evaluation following the liposuction surgeries.

In comparison to UAL, the endoscopic view following water jet-assisted liposuction shows fewer intact septal fibers.
LIPO RANKINGS "In the PAL technique, the cannula gently vibrates and shakes its way through the fat. I found this technique to be the most effective, the most gentle, and the least traumatic to the subcutaneous tissues, which was verified on endoscopy," Dr. Fatemi notes. "The classic or manual SAL was second." The third technique, UAL, works by emitting an ultrasonic frequency designed to rupture the fat cells as the cannula proceeds through the subcutaneous fat. This is beneficial as the ruptured fat cells can be more easily siphoned. Unfortunately, according to Dr. Fatemi, the UAL technique also ruptures much of the septae that is needed to hold the natural contour. Furthermore, common ultrasonic cannulas are large in diameter, limiting their use to certain areas of the body. Another consideration in UAL is tumescence. The modern pre-step to liposuction is the injection of a tumescent solution in order to separate the tissues from each other, as well as assist in breaking up the fat tissue. It is readily used in SAL, PAL and WAL, but according to Dr. Fatemi, is not as commonly employed—or at least not in the same amounts—in UAL. Dr. Fatemi adds that burns can also occur with the ultrasound technique.

HITTING THE 'WAL' In the fourth technique he assessed, WAL, high pressure water is sprayed through the cannula as the probe passes through the tissues. Dr. Fatemi found this technique to be the most traumatic and, therefore, the most disadvantageous to septal structure integrity. "This technique may be a lot quicker to perform," explains Dr. Fatemi, "but the high-pressure water does not discern between fat tissue and any other subcutaneous tissue in its path, often causing more harm to underlying structures such as the septal fibers and blood vessels. This could be verified in the endoscopic examination as well as in the contour results following the liposuction procedure," he says. According to Dr. Fatemi, necrosis is a typical adverse event following both UAL and WAL procedures. However, necrosis is a very uncommon sequela following PAL. This is directly related to the amount of trauma induced from the procedure, he explains. "The techniques that are not so gentle with the tissues not only remove the septal fibers, but also the blood supply to these subcutaneous tissues, causing the necrosis. The more traumatic the technique used, the higher the risk of adverse events," Dr. Fatemi says. Another by-product of overly aggressive liposuction is the creation of strictures. A stricture can be likened to a subcutaneous scar that causes a dimpling of the skin. Strictures can occur if too many septal fibers or fat is removed, leaving the skin juxtaposed to the muscle tissue. "Cosmetic surgeons might want to opt for the PAL or SAL techniques, especially if they lack experience in liposuction surgery," Dr. Fatemi counsels. "These 'beginners' should stay away from the WAL technique as it requires a great deal of experience and is a very unforgiving technique to the inexperienced surgeon."

For more information
Afschin Fatemi, M.D.
[email protected]

Hide comments


  • Allowed HTML tags: <em> <strong> <blockquote> <br> <p>

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.