THIS SITE IS ONLY FOR DOCTORS !!!

Ziya Saylan MD, Düsseldorf, Germany

ABSTRACT: This article is a result of using an ultrasound liposuction machine for four years. It is also a comparison of the ultrasound liposuction method to the conventional method. The author had published1 his experiences for the first time in 1994 and in the following years he had the possibility to work more with this device and gain more experiences. Meanwhile we have observed that the long term results of the ultrasound liposuction are the same as of the conventional technique. The propagated skin lift effect of the ultrasound disappears after a few months, and it is not possible to apply superficial liposuction with the ultrasound cannulas, because they are very thick and may cause skin burns due to the produced heat . In our comparison the skin results were the same after six months. We have observed that ultra-sound liposuction at the knees, inner thighs, arms and ankles has proven not to be very successful. The advantages of the ultrasound method are reduced pain, reduced bruising, lower amount of blood in the aspirate and a short recovery period. We have found out that the slow movement of the ultrasound can-nula and the low suction pressure are the reason for that, and not the ultrasound itself. The most com-mon disadvantages are; the very high expenses, the high rate of corrections ( re-liposuctions), poor re-sults, the long duration of the operations and the impossibility of using the aspirated fat again.

HISTORY: In Europe the ultrasound instruments are known since 1991. This method is still not approved by the FDA in the USA. One of the devices is also not approved in some European countries. We have two different instruments in Europe ( Zocchi8 and Lipectron1 ) achieving almost equal results. My interest in ultrasound liposuction developed as follows: I first became aware of the ultrasound liposuction in 1991 when I visited a colleague in France. Afterwards, during the Annual Meeting of the French Cosmetic Surgeons in Paris3 in June of 1993, I could try the instrument and I bought it then. I was hoping to be a witness to a big revolution in liposuction and to do wonderful work achieving great results. One of the distinct advantages in using this instrument, as I was told , was that it significantly reduces the physical stress on the surgeon during the operation, and at the same time it increases the safety for the patient through less bleeding, less swelling and a short recovery time. But after a few months I was dis-appointed with the results and beginning to have doubts that perhaps I was doing something wrong. I have talked to other colleagues who were also using ultrasound, I visited them in their offices, watched them use ultrasound. I have seen that most of them also have the same problems. In the end I sold my device. I also know of other doctors intending to sell their ultrasound devices.

In Europe the ultrasound instrument costs1,8 about $30.000, and the disposable suction tubes, which only fit this device, cost $50 for every suction. Once a year the whole instrument has to be re- adjusted and controlled, and that also costs $ 500. After starting to do liposuction with the ultrasound we had to increase our prices about 50-100 %. We had to explain to our patients why we were more expensive than other colleagues. On the other hand, some patients liked to be liposuctioned with a high-tech tech-nique, and they were ready to pay the extra expenses. It was also very profitable for us to advertise this new device, which was a product of high technology. We were in the newspapers and on TV. The Media always shows great interest in such progressive instruments.

The mechanism of ultrasound liposuction: The ultrasound liposuction works by damaging the fatty tis-sue, causing the cells to explode and leaving the cell membranes behind. The remaining cell mem-branes are supposed to act like collagen tissue and give the skin extra strength, which is responsible for the smoothness and the skin lift-effect. Meanwhile we observe the same kind of tissue changes after the liposuctions with microcannulas. Ultrasound liposuction is supposed to cause less bleeding and less pain due to reduced vessel and nerve injuries. This, in our opinion, is also not only due to the ultrasound technique, because we have found out that in order to let ultrasound work, the manufacturer1 advise to move the cannula very slowly and to apply low suction pressure, because otherwise the cannula will get blocked.

In the beginning, it was hard to get used to the ultrasound cannula. It has a thick and heavy handle with three tubes and a cable. The heavy handle, which weighs almost 400 g, does not always allow you to work with feeling and tenderness. The tunnelling and the aspiration has to be done very slowly in order to
allow time for the ultrasound device to dissolve the fat . This procedure has to be carried out very slowly, otherwise the ultrasound device will act like a pump aspirator. In our study we were only able to aspirate 1 (one) kg of fat per hour with ultrasound liposuction, which is very slow and increases the duration of the operation. This will also increase the expenses, the possibility of cardiovascular problems and the rate of infections during liposuction. Also, the fatty tissue that has been aspirated by means of ultrasound is destroyed and cannot be used for lipofilling purposes.

The general Considerations: In the beginning, I thought that ultrasound liposuction was the treatment of the future with plenty of advantages. The amount of blood in the aspirate was very low, which allowed us to aspirate more than usual. At first we thought that it was a result of the Ultrasound, but as we tried to do liposuction without ultrasound, also very slowly, with low suction pressure and in a longer period of time, there was also a reduced amount of blood loss. If the surgeon is not careful enough, the machine only aspirates and the ultrasound may not be working properly. In other words - without knowing - the surgeon will do usual pump liposuction instead of ultrasound liposuction.

With the patients' consent, we decided to apply a conventional and a ultrasound liposuction on the dif-ferent legs of the patient.s. That made it possible for us to differentiate which one achieved the better results. Long term results showed that in almost 50% of the ultrasound cases a correction was neces-sary in comparison to 15% corrections needed in the conventional liposuction, and that made us think about it. This was also the observation of many other colleagues2,4. Our euphoria was gone, and we started to try to combine both methods. Afterwards, as we started to do liposuction with microcannulas, we saw the best results of all times, and that persuaded us to change to microcannulas.

29 cases of cellulitis have been treated with ultrasound liposuction, all with considerably good results in the beginning. The treatment of cellulitis with ultrasound liposuction was at that time believed to be more successful, but the skin lift effect was gone after a few weeks, and after 6 months there was no differ-ence between the conventional and the ultrasound techniques. Meanwhile we are using small caliber cannulas (1,4 to 2 mm microcannulas) with much more better results, even after one year. Superficial liposuction with small caliber cannulas is the best possible surgical solution for cellulitis, and it achieves better results than the other methods. This would not be possible with the ultrasound liposuction tech-nique because they don't offer small and long cannulas.

Small ultrasound cannulas cannot be manufactured because of a technical problem. They cannot be built small enough because of enormous heat problems5, and an appropriate water cooling system can-not be installed. The small caliber cannulas can get too hot, which in turn damages the skin and the sub-cutaneous tissue ( reason for skin burns during ultrasound liposuction ). To prevent this danger, some devices9 have a plastic funnel, and the ultrasound cannula will be inserted through this funnel into the body. The production of heat is also present in the tissues, especially where the ultrasound waves cross each other and build knots. These places can not be cooled, they are deep inside the body, and we don't know what happens there. For that reason some companies advise not to do ultrasound liposuction on the chest, because of the mediastinal organs, and on the epigastrium because of the solar plexus. There is a need for more measurements and experiments to explain this situation. The physicists are very sceptical about the use of ultrasound close to vital organs6.

Another important fact is that we don't know which amount of ultrasound waves is necessary for different kinds of tissues. All the dosages given are subjective and without any scientific foundation. The abdomi-nal wall and the hips are being liposuctioned with the same dosage of waves. According to the physicists it is not correct to ultrasound the abdomen and the extremities with the same amount of waves.

The patients that had undergone ultrasound had less pain in comparison to the classic method, how-ever they complained about a strong burning sensation of the inside tissue. Some of these patients needed analgetics because of the severe feeling of burning under the skin.

Results of cases:
74 patients had undergone ultrasound liposuction with aspiration at 97 different body parts. At the same time we had chosen 165 patients for the conventional liposuction. We compared both groups of patients with the following results.

Part of the body Ultrasound liposuction n: 74 Conventional liposuction n: 165
Submental Poor results, cannula to big for a proper suction. Correction >50% Better results.Syringe aspiration achieves the best results. Correction < 15%
Breast Not advised because of the fear of injur-ing the mediastinal organs. Good results. A good solution for a breast reduction if the breast is not too large.
Abdominal wall Prolonged Operation time. Not advised if big amounts to be suctioned. Othewise good results possible. Correction > 50%. Good results. No injury due to waves possible. Correction < 10%.
Saddle-bags and Buttocks Good results. Operation time is pro-longed. Liposuction of big quantities should be avoided. Correction >25% Good results especially with microcannu-las which can also prolong the operation. Correction < 12%
Thigh and Knee Poor results. Cellulitis treatment in short terms seems to be better. Long time re-sults shows no effect of skin lift as propa-gated. Correction > 30%. Better results with microcannulas. Super-ficial liposuction can be applied easily without any skin burns. Correction < 5%.
Lower leg Very poor results because of thick cannu-las. Correction >50%. Very good results. Suction can be done with small cannulas even on ankles and feet. Correction <5%

Advantages
1. The biggest advantage in my opinion is to advertise a high-tech device which some patients love to hear, and only for that reason they will visit your office. The media always shows a big interest in new techniques, and if you work with ultrasound liposuction, you will be on TV and in newspapers. The results will not be asked for so often. Everybody talks about the progress in technology and the prices. A low-cost treatment doesn't impress some patients.
2. The better skin results which I have mentioned before are not permanent. After 6 months the skin lift effect was gone and the long term results were the same. The only real difference is in the fact of less bruising and swelling occurring with the ultrasound liposuction in comparison to the conventional method. In my opinion it can also be the result of less suction power ( minus 0.4 - 0.5 atmosphere in comparison to conventional suction of 0.8 to 1 atmosphere ) and the smoothness of the strokes during the suction. In order to let ultrasound be effective you have to move the cannula very slowly and tenderly which causes less injuries.
3. Less pain in the ultrasound liposuction. Instead of pain, the patients are complaining about a burning and heat feeling in the area which has been liposuctioned. This is also very uncomfortable for the patients, and the physicians are forced to give the same amount of analgetics as in the conventional liposuction.
4. Less bleeding is perhaps also as a result of the smooth movement of the ultrasound cannula and the reduced suction pressure. But I have to admit that in the cases where we applied ultrasound liposuction there was less bleeding.

Disadvantages
1. The suction is very slow with less number of strokes per minute with a low suction pressure that prolongs the suction, in other words the operation time, 3 - 4 times.
2. In Germany, an ultrasound instrument1,8 costs about $ 30.000, and the disposable suction tubes that only fit this device cost $50 for every procedure. Once a year the instrument has to be adjusted, which costs $ 500. You have to increase your prices about 50-100% in order to finance your expenses.
3. The handle of the cannula is heavy ( about 400g ) which makes it hard to work with the cannula. If you are used to work with light cannulas you will have problems in the beginning.
4. Almost 50% of the patients who had ultrasound liposuction of the abdominal wall required a corrective Liposuction2,4,7.
5. The fat that has been aspirated with the ultrasound technique is destroyed and cannot be used for lipofilling purposes.
6. There is no evidence that the organs in the Epigastrium and the Mediastinum cannot be injured with the ultrasound waves5. More studies are required to explain this question.
7. The ears of the surgeons and the nurses have to be examined every 3 months, because there is also the possibility of an acoustic injury caused by ultrasound waves. The physicians say '' what destroys the fat can also destroy your ears''.
8. The ultrasound liposuction takes much longer than the conventional technique, which increases the operation room expenses and the duration of the anaesthesia.
9. If the surgeon is not careful - without knowing - he will use the ultrasound device as a pump aspirator, because they both work together. When the ultrasound weakens or stops, the suctioning continues. It is not possible to measure how many ultrasound waves the tissue is receiving.
10. The missing small cannulas of ultrasound liposuction are a handicap. The thick ultrasound cannulas do not allow a superficial suctioning. The treatment of cellulitis is not proved to be more successful with the ultrasound technique.

Conclusion: After all, I have to say that the ultrasound technique that is used nowadays is not better than the conventional technique and the microcannulas. Much more research in to the ultrasound instrument is needed in order to improve it.

References
1. Medicamat Company / Lipectron Ultrasound Instrument for Liposuction. 59, Avenue A.
Dumont- 92240 Malakoff, France
2. Marinetti C.: Liposculpture ultrasonique. Etude clinique prèliminaire des differents para-
mètres et des rèsultats. Lecture at the Liposuction meeting in Marseille-France, March 1994
3. Societe FranVaise de Chirurgie Esthetique, 8. Congres International de la Societe Francaise de Chi-rurgie Estetique 22-23 mai 1993 a Paris.
4. Bureau H., Marinetti C. : Liposculpture ultrasonique contre lipoaspiration traditionelle Etude contro-laterale comparative. Lecture at the Liposuction meeting in Marseille, March 1994
5. Personal Conversation, Medro Company, Düsseldorf, Germany. October 1996
6. Acet, Prof. Dr. M. University of Duisburg, Germany. Department of Experimental Physics.
7. Saylan, Z. Comparison of the Conventional and the Ultrasound Method of Liposuction, Am Jour Cosm Surg., Volume 12, No.3, pp 219-220, 1995
8. Smei. Ultrasound Instrument. Via Vercelli 13, 15033 Casale Monferrato, Italy
9. Zocchi, M., Ultrasonic Liposculpturing. Aesth. Plast. Surg. 16:287-298, 1992