Nicola Zerbinati MD
Centro Medico Poliambulatorio
Laserlipolisi is a new, innovative liposuction technique that uses a pulsed Nd:YAG laser system. The light energy is emitted by the laser source through a thin quartz fibre that does not cause any power loss. The distal part of this fibre is protected by a 1mm stainless-steel cannula that is introduced into the subdermal tissue. The interaction between the laser energy and the adipocytes causes lysis of fat cell membranes, which results in their contents leaking out before being dispersed in the interstitial tissue. The laser light also reduces bleeding and promotes collagen retraction and skin shrinkage in collagen fibrils. This method is more precise and less traumatic than conventional surgery – with so many advantages it can be considered as the new frontier in liposculpture.
New techniques and innvoations
Before the 1970s fatty tissue was extracted in lumps by means of large cutaneous incisions, which produced extensive scarring. During the 1970s Italian and French surgeons experimented independently on a new method for removing excess fat. Today this technique is known as liposuction, lipoaspiration or liposculpture. The greatest innovation used cannulas to remove large quantities of fat through reduced incisions and, as a result, reduced scarring. An American surgeon introduced an upgrading of the liposuction technique in 1987. This new technique is known as tumescent liposuction surgery, where large quantities (several litres) of an adrenalin and anaesthetic solution are injected into the areas of fat to be aspirated. Finally, during the 1990s, an ultrasonic vibrating cannula technique was introduced that increased the volume of removable fat.
All these techniques have one big disadvantage – the limited possibility of modelling the areas treated, as the cannula creates subcutaneous hollows that are difficult to fill. Another disadvantage is the rupturing of veins in the fat tissue coupled with considerable blood loss and subsequent haematomas that require long-term bandaging. All these are significant problems in view of the fact that lipoaspiration requires general anaesthesia, allows for removing a litre of fat per session and, in some cases, requires blood transfusion with slow recovery times accompanied by widespread haematomas.
With Laserlipolisi anaesthesia may be local, peridural or general. We prefer to use this technique only with local anaesthesia for sessions limited to one hour or one and a half hours. A small incision of 2mm is made where the cannula is introduced. The cannula has 1mm diameter with an optical fibre inside and, to our knowledge, there have been no reports of fibre breaks during sessions. The surgeon controls the motion of the cannula by a handpiece; speed must be relatively slow, as compared with conventional liposuction, to allow the necessary time for laser–tissue interaction. Sufficient accumulated energy must be delivered to achieve a sufficient lipolysis throughout the different levels of fat tissue (superficial, medium and deep) and into the subdermal layer, to reach the collagenous one. After lipolysis, the liquid fat can be aspirated using a 2 or 3mm cannula (with low negative pressure, no more than 0.5 bar), or a standard syringe. The laser energy transforms the fat tissue into a lysate with a very low viscosity, very similar to that of an oily liquid. We prefer to leave this lysate in situ when we use this technique on small areas such as the face, neck, arms and knees. This is an important advantage – due to the small diameter of the cannula, it can be used on all parts of the body where a fat layer is present.
Badin et al were surprised to have reduced flabby skin after the use of Laserlipolisi procedure.(1) They treated 245 patients in 12 months with no side-effects; the only clinical problem was undercorrection, because of insufficient delivered energy in their earliest cases. Goldman et al used Laserlipolisi on 1,734 patients in 28 months with similar results, with no significant side-effects, very low blood loss, low incidence of ecchymoses and great comfort in the postoperative period.(2) This is also our experience, and people can return to their normal daily routine after only a few hours. No restrictions are necessary, although sun exposure should be avoided for a month.
This method was demonstrated to be less traumatic than conventional liposuction methods thanks to the cannula’s small diameter and the effects of the laser–tissue interaction. The laser–tissue interaction causes thermal damage to the cellular membrane through the liberation of heat and alteration of the Na(+)K(+) ”bomb”, which lets water migrate into the cells until they rupture. This is visible in the pathologic anatomy, where we see different-sized cells after membrane rupture. We can also see the reduction in bleeding that results from the coagulation of small vessels due to the laser and lateral thermal effect. Moreover, due to the laser–tissue interaction with the collagenous and subdermal bands, we can see the thermal effects, including melting and rupture of the bands. This liberates the retracted skin and remodels the collagenous tissue, with clinically evident skin retraction. Clinically, this tissue interaction produces less swelling, yielding good contours, even in the early postoperative period. Ichikawa et al showed the capability of the Nd:YAG laser system to transform the subcutaneous tissue in an oily lysate without any carbonisation.(3) This is thanks to the pulse shape of the laser used in this technique (SmartLipo, Deka, Italy). The peak power and duration of the pulses have been adapted to avoid any risk of thermal damage, which is very important for limiting side-effects (eg, bruising and swelling or scars).
Indications for this method of laser-assisted liposuction are: small areas; areas of current, moderate flaccidity; areas with potential for flaccidity; a history of conventional liposuction; multiple-area, high-volume liposuction in highly vascular areas, such as scapula, waist, flanks (dorsum); secondary liposuction in areas with irregularities and/or fibrosis; difficult cases (eg, the upper portion of the thigh, upper abdomen); and small areas with minimal excess fat, such as minimal periumbilical fat.
This new technology offers a method that addresses problems previously considered difficult or impossible to solve with conventional liposuction and also permits treatment of nearly any area of the face or body needing liposuction – a clear advantage over ultrasonic liposuction. This methodology can be added to our clinic because it is an excellent tool for particular cases, including areas of moderate or potential flaccidity, small or minimal areas, secondary liposuction and difficult cases. In our clinical experience it has proved to be less traumatic, with less bruising and swelling, and improved skin retraction, all demonstrated in published pathology studies.