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Original ArticleEvaluation of the safety of VASERTM in liposuctionsurgery to improve body contourAvaliação da segurança no emprego do VASER em cirurgia delipoaspiração para melhora de contorno corporalFELIPE MASSIGNAN 1*Institution: Centro Hospitalar Santa Mônica,Erechim, RS, Brazil.Article received: April 4, 2019.Article accepted: October 20, 2019.Conflicts of interest: none. ABSTRACTIntroduction: Liposuction has been improved continuouslysince it was first introduced. The third-generation ultrasoundtechnology VASERTM (Vibration Amplification of Sound Energyat Resonance) facilitates liposuction, providing improvedsafety and satisfactory results, especially in the search forgreater definition and superficial liposuction. Methods:From 2015 to 2017, 76 patients underwent liposuction toimprove their body contour at the Santa Monica HospitalCenter in Erechim, Rio Grande do Sul, Brazil. The results,complications, and the safety of VASERTM were evaluated.Results: The routine use of VASERTM improves body contour.The emulsification generated by the device, along withliposuction, resulted in greater definition and revelationof the anatomical landmarks. Conclusion: Liposuctionassociated with VASERTM allows plastic surgeons to refinethe results better while ensuring patient safety is maintained.Keywords: Tissue; Lipodystrophy; Postoperative complications;Subcutaneous fat; Patient safety; Body contour.DOI: 10.5935/2177-1235.2019RBCP02251458Centro Hospitalar Santa Mônica, Centro Hospitalar, Erechim, RS, Brazil.WSW

Evaluation of the safety of VASERTM in liposuction surgery RESUMOIntrodução: A lipoaspiração tem sido submetida à evoluçãoconstante desde a sua consolidação e emprego sistemático. Oauxílio de tecnologia ultrassônica de terceira geração, VASER (Vibration Amplification of Sound Energy at Resonance), sedestina a facilitar a execução da lipoaspiração e trazer maiorsegurança e resultados satisfatórios, especialmente na buscapor maior definição e lipoaspiração superficial. Métodos:No período de 2015 a 2017, 76 pacientes foram submetidasà lipoaspiração para melhora de contorno corporal noCentro Hospitalar Santa Mônica em Erechim. Foramavaliados os resultados obtidos, as possíveis complicaçõese a segurança do emprego do VASER . Resultados: Autilização rotineira do VASER gera aperfeiçoamento deresultados em contorno corporal. A emulsificação geradapelo dispositivo associada à lipoaspiração em diversosníveis permite uma maior definição e evidenciação dosmarcos anatômicos. Conclusão: Lipoaspiração associadaao VASER permite ao cirurgião plástico o refinamento deseus resultados com a preservação da segurança do paciente.Descritores: Tecido adiposo; Lipodistrofia; Complicaçõespós-operatórias; Gordura subcutânea; Segurança do paciente;Contorno corporal.INTRODUCTIONLiposuction is one of the main proceduresperformed by plastic surgeons. Over time, a number ofimportant innovations have been made to traditionalliposuction, which have resulted in greater comfort forthe surgeon as well as better results1.Historically, several approaches have been usedto remove adipose tissue during liposuction2. Over timethe procedure has been refined, and improvementswere made to improve various aspects of the procedure,such as the surgical technique, the cannulas employedand the use of adjuvant devices.In a sense, this will be a continuous journey.There are no particular objectives, but only goals.Traditional liposuction remains a somewhat strenuousprocedure with limited tactical variations. Therefore,initiatives capable of generating a reduction in theload and mechanical stress or amplifying the handlingof the subcutaneous cell tissue variations can helpoptimize lipsuction3.The use of ultrasound in surgical procedures isnot new. Zocchi, in 19954, became a pioneer in applyingultrasound to emulsify fat selectively so as to contourthe body. The first-generation devices for ultrasonicassisted liposuction were developed by SMEI, Italy. TheRev. Bras. Cir. Plást. 2019;34(4):458-467SMEI appliance consisted of solid 4–6 mm probes thatemulsified the fat at a frequency of 20 kHz.Second-generation devices were introducedin the 1990s, such as the Lysonix 2000 (Lysonix Inc.Carpenteria, CA). In this case, emulsification andaspiration occurred simultaneously through a “golftee” and “bullet design” cannula at a frequencyof 22.5 kHz. During the same period, the MentorCorporation introduced its body contouring devices,Mentor Contour Genesis Devices, with a hollow 3.0mm and 5.1 mm cannula at a frequency of 27 kHz. Theexcessive transfer of energy to the tissues combinedwith the elimination of the protective layer fromthe simultaneous extraction resulted in significantcomplications5.The popularity of ultrasonic-assisted liposuctiondecreased by the end of the 1990s. In 2001, SoundSurgical Technologies introduced VASERTM (VibrationAmplification of Sound Energy at Resonance), a thirdgeneration device that was created to improve safetyby reducing the energy transferred to the tissues whilemaintaining efficacy6.VASERTM has a solid probe that emulsifies fatefficiently at 36 kHz while preserving nearby tissue.The tunable nature of the system allows almost allareas of the body to be treated safely and effectively.459

Massignan F et al.www.rbcp.org.brCurrently, VASERTM is considered the gold standard inhigh-definition body contour7.In VASERTM, the resonance uses a frequency of36 kHz, which is close to the resonance of fat. For thisreason, a lower energy is transferred to other tissue.Moreover, adipose cells are much larger than otheradjacent tissues, such as blood vessels, nerves, andconnective tissue and, therefore, are more susceptibleto ultrasonic energy8.The appliance uses 2.2–4.5 mm diameter probeswith grooves near the tip to increase the energytransmission efficiency and fragmentation of fat. A largerprobe results in more ultrasonic energy being dispersed.The device also has a pulsed ultrasonic energy deliverymode. This method uses high vibration frequencies withnon-continuous activation, decreasing the total tissueenergy applied while maintaining efficacy9.OBJECTIVEThis study aimed to evaluate the safety of athird-generation ultrasonic device, VASERTM, withliposuction surgeries to improve body contour. Thedata obtained in this study were compared with theexisting literature.METHODSThe study consisted of a retrospective reviewof medical records of patients who underwent aliposuction procedure with the aid of VASER TM,from January 2015 to June 2017, at the Santa MonicaHospital Center in Erechim, Rio Grande do Sul, Brazil.The data and the methods used were approvedby the Ethics Committee of the Santa Monica Hospital,Erechim/RS, Brazil. Record 002/2018.Selection of patients as well as inclusion andexclusion criteriaThe patients included in the study were maleor female, aged over 18 years, with localized excesssubcutaneous fat. The exclusion criteria were: Patients with a limiting clinical condition; Women in the first year after birth, werepregnant or lactating; A body image disorder; Inflammatory conditions of the skin in thetarget area of surgical therapy; Obesity (BMI 30); Concomitant abdominoplasty surgery.We included 76 patients in our study. Femaleswere the most common gender, with 74 patients,accounting for 97.36% of the sample. Two male patients(2.67%) underwent liposuction with VASERTM. Theaverage age of the women in the study was 39 yearsold (21 to 65 years) and 37 years old for men. The meanBMI of the sample was 24.64 kg/m2 (Table 1).Evaluation CriteriaGiven that liposuction was performed, we usedthe routine criteria mentioned in the current literatureregarding surgical complications. These can beclassified according to the occurrence period.Preoperative evaluationAll patients were evaluated before surgery bythe anesthesiology team of the Santa Monica HospitalCenter. Laboratory and complementary examswere requested in accordance with their age andcomorbidities. Patients were under general anesthesiafor the procedure (Table 2).Table 1. Procedures performed.Procedure performedNumber of PatientsLiposuction in the abdominal region, flanks, and dorsum.31Liposuction in the abdominal region and dorsum with the placement of breast implants.20Liposuction in the abdominal region, flanks, and dorsum with mastopexy.8Liposuction in the abdominal region and mastopexy with the placement of implants.5Liposuction in the abdominal region, flanks, and dorsum with mastopexy and placement of implants.3Liposuction in the abdominal region with the placement of breast implants.3Liposuction in the lateral face of the thigh with the placement of breast implants.2Liposuction in the abdominal region.1Liposuction of the abdominal region, flanks, and dorsum with correction of gynecomastia.2Liposuction of the lateral face of the thighs.1460Rev. Bras. Cir. Plást. 2019;34(4):458-467

Evaluation of the safety of VASERTM in liposuction surgeryTable 2. Complications.Perioperative complications(0–48 h)Skin necrosisInjury due to the cannula, portal orendpointAnesthetic ComplicationsPostoperative complications in recent(1–7 days)Complications in the late postoperativeperiod (1 week–3 months)CelluliteSeromaParesthesia, transient or permanentalteration in sensitivityProlonged lications – Ultrasonic-assisted liposuctionVASERTM TechnologyUltrasonic technology is based on the conversionof electrical energy in sound vibrating waves througha handpiece. This vibration moves through a titaniumprobe at a constant frequency of 36 kHz. The interactionof probe designs with tissue sound reverberationregulates the effectiveness of the system2.Subcutaneous tissue, which is in a humidenvironment, receives the sound energy coming fromthis probe. There are two operating mechanisms. Thefirst, and less frequent, breaks down the cell membraneby direct impact. The second is called cavitation.The vibratory frequency of the sound wave producescompression and rarefaction forces (cavitation), whichare issued by its distal rings, with small air bubblesforming. These bubbles will gradually increase indiameter and simultaneously englobe the adipocytes intheir interior until they rupture. The energy released bythe rupture of the microbubbles releases the adipocytesfrom the tissue microarchitecture8.Cavitation and the mechanical rupture of tissueare selective, i.e., the diameter of fat cells are largerthan the adjacent tissue microarchitecture (bloodvessels, muscle fibers, connective tissues). Therefore,these remain intact8.The appliance has enough power and accuracyto treat different body areas without the need to useloading to overcome areas of tissue resistance6.The VASERTM is composed of an integratedsystem, formed by a display (ultrasound), handpiece,probes (special atraumatic rods), aspiration tower usingthe Ventx system (ventilated suction system), integratedirrigation system, and drive pedals. This entireapparatus brings together all the necessary equipmentto perform liposuction surgery in an organized manner.This helps to ensure safety, comfort, and practicality inusing the device8 (Figure 1).Skin PortsProtective parts used in surgical accesses areroutinely inserted into the gluteus sulcus, anteriorand posterior axillary topographies, pubic region,Rev. Bras. Cir. Plást. 2019;34(4):458-467Figure 1. VASERTM System (Vibration Amplification of Sound Energy atResonance). Source: The Author (2018)461

Massignan F et al.navel, and inframammary sulcus. They prevent andprotect these areas from thermal lesions occurringdue to ultrasonic vibrations and trauma of repetitivemovements (Figure 2).www.rbcp.org.brCannulasAtraumatic cannula system for collectingemulsified tissues, with amplitudes and configurationsfor variable anatomical units6 (Figure 4).Figure 2. Portals with a suitable design for varying the diameters of theultrasonic probe. Source: The Author (2018)HandpieceSound pulse conduction instrument connecteddirectly to the ultrasound with inserts for the probes.They require continuous revision of “wrench” fitting todissipate the sound wave vertically (Figure 3).Figure 4. Set of VentxTM cannulae, from top to bottom: Adaptation handle, 3.0mm infiltration cannula, 3.0 mm liposuction cannulae, 3.7 mm, 4.6 mm short,4.6 mm long, 5.0 mm basket cannula, 4.6 mm curved cannula, baby armpitcannula, 3.0 mm Toledo cannula, 3.0 mm lower limbs cannula and 4.0 mmcannula for fat grafting. Source: The Author (2018)ProbesThe equipment has probes of different diameterswith grooves near the tip to transmit power. The larger thediameter of the probe, the greater the dissipated energy.Formatting for all anatomical units is available7 (Figure 5).Figure 5. VASERTM ultrasonic probes. From left to right: 4.5 mm probe, 3.7 mmprobe/2 rings, 3.7 mm probe/3 rings, arrow probe and 2.9 mm probe/3 ringsand Saturn probe. Source: The Author (2018)Presurgical markingFigure 3. Handpiece with probes and a wrench. Source: The Author (2018)462During the physical assessment, an analysis of thedistribution of adipose tissue in different parts of the bodyis established. This includes documenting the thicknessof the abdominal and trunk fat, as well as muscle mass.Rev. Bras. Cir. Plást. 2019;34(4):458-467

Evaluation of the safety of VASERTM in liposuction surgeryWe use routine VASER TM instead of a bodycontouring liposuction procedure as the surgicalprotocol indications are identical, with no exceptions.We begin with the patient in the orthostaticposition, and the first anatomical landmarks delimitedare the areas in which the withdrawal of 100% of thelamellar layer of subcutaneous tissue is planned. Then,the rectus abdominis muscles, the anterosuperior iliaccrests, and the inguinal ligaments are identified. Thetopography of the gluteus maximus muscles, the sacralconcavity, and the transition between the upper andlower back following the lumbosacral fascia syncopeare also delimited (Figure 6).Figure 7. Patient in dorsal decubitus with safety portals in the pubic area,the upper edge of navel and inframammary sulcus (prorings). Source: TheAuthor (2018)InfiltrationFigure 6. Blue: delimitation of deep extraction. Black: delimitation ofstrategic anatomical points. Lilac: transitional areas of superficial relief.Green: Region of total extraction of lamellar layer and partial extraction ofareolar compartment. Red: alert area to avoid excessive resection. Source:The Author (2018)Surgical techniqueThe preparation of the patient in the surgicalcenter begins with anesthesia; we prefer using generalanesthesia. After that, a delayed bladder catheter, socks,and intermittent venous compression equipment for thelower limbs and body warming systems are prepared.The surgery is standardized in three stages:infiltration, emulsification, and aspiration.PositioningThe patient is positioned in ventral decubituswith ample exposure of anatomical units and, after theend of this step, changed to dorsal decubitus. In bothpositions, strategic portals are placed in masking areas(back: intergluteal sulcus and in posterior axillary foldtopography. Abdomen: in the pubic region, umbilicalscar, inframammary topography, and anterior axillarytopography). These accesses receive, after infiltration,protectors (skin ports) to slide the probes, avoidingadjacent thermal injuries (Figure 7).Rev. Bras. Cir. Plást. 2019;34(4):458-467The super humid infiltration technique isused for both superficial and deep regions. Theroutine volume used is 1:1 (infiltrate volume/aspiratevolume), with a warm saline solution and epinephrine(1 ampoule for each 1000 mL saline). The solutionis inserted through the previously made portals.The adjacent region needs to be kept moist duringthe surgical stages with a physiological solution todissipate better the thermal energy generated by thedevice and friction.EmulsificationThe introduction of the probes follows theworking movement practiced in traditional liposuction,that is, back and forth movements, without force, feelingthe device cross the tissues. This process begins withthe lamellar layer and ends in the areolar compartment.The recommended duration of VASER TM ,according to guidelines from the manufacturer,is approximately 1 minute for each 100 mL ofinfiltrated solution, to generate the feeling of a “lossof resistance”. Areas of higher fat content can beaddressed with a larger diameter probe and with theappliance power up to 80% in continuous mode. Inless thick areas, such as the waist, smaller probes, 2.9mm, with 3 rings (greater lateral dispersion of energy)and the appliance power up to 60%, in pulsed mode,is recommended.The superficial use of the VASERTM is performedwith a 2.9 mm probe, 3 rings, and in pulsed mode.This step is responsible for the retraction of the skin,offsetting the areas of myofascial flaccidity, especiallythe hypogastrium. The duration of the emulsificationstage in our routine is approximately 30–45 minutesin each decubitus (Table 3).463

Massignan F et al.www.rbcp.org.brTable 3. VASERTM system m/Large3.7 mm (3 grooves)Continuous70–80SmoothSmall2.9 mm (3 grooves) or3.7 mm (2 grooves)Pulsed or continuous70–80Slightly fibrousMedium/Large3.7 mm (2 grooves)Continuous80–90Slightly fibrousSmall2.9 mm (3 grooves) or3.7 mm (1 grooves)Continuous80–90Very fibrousMedium/Large3.7 mm (2 grooves) or3.7 mm (1 groove)Continuous80–90Very fibrousSmall2.9 mm (3 grooves)Continuous80–90Length of probesLIPOSUCTIONthe cannula when sliding through tissue, in particularto the subdermal plexus, does not damage it (Figure 8).Lamellar layerThe aspiration of fat follows the conventionaltechnique of tissue collection, that is, “fan-shaped”and with a “spread hand,” feeling the movement ofthe cannula. Tissue resistance is minimal, given thatthe density of the tissue is markedly decreased byemulsification. The cannulae used have a diameterof 3.0 mm, 3.7 mm, and 4.0 mm. The aspiration of thetissue is always initiated by the deep layer, with greaterdiameter cannulae (3.7 mm and 4.0 mm).Areolar layerFigure 8. Example of liposuction with approaches of the various levels oflamellar fat anatomical relief, joint thinning of the subcutaneous cellulartissue in areas of tendon encounters and the adjacent anatomical transitionsThe superficial emulsification and liposuctionare performed selectively on the edges of the musclegroups (alba line and inguinal ligament). Thinnercannulas are essential.After the end of the liposuction step, weintroduce a continuous aspiration drain (PortoVac) inthe lumbosacral and suprapubic regions.TransitionPostoperative managementThis phase is used to ease the transition betweenthe muscle groups and the sharp edges in the superficialliposuction, promoting the withdrawal of excess musclefat, with an improvement of the definition of theanatomical landmarks superficially. The goal is thedemarcation of the lateral edges of the muscle groups,with the maintenance of a pinch test of around 1 cm.Patients use a compressive modeling mesh andvenous return pump throughout their hospital stay.On the second postoperative day, patients begin dailypostoperative lymphatic drainage for at least 10 days.Superficial subdermal liposuctionThis consists of aspirating superficial subdermalfat through thin 3.0 mm and 2.0 mm cannulae. Byreducing the fat just below the skin, it is possibleto obtain effective skin retraction. The Ventxsystem enables continuous negative pressure in theliposuction cannula. Consequently, the aggression of464RESULTSIn this retrospective study, we performedan analysis of the medical records of patients thatunderwent liposuction using the VASERTM systemto assess the surgical complications found. We thencompared our findings with the existing literature.Our main goal was to evaluate the safety ofthe VASERTM device. Other data such as the volumeinfiltrated and aspirated solution, the mode of energyused (pulsed or continuous), and application time

Currently, VASER TM is considered the gold standard in high-definition body contour7. In VASERTM, the resonance uses a frequency of 36 kHz, which is close to the resonance of fat. For this reason, a lower energy is transferred to other tissue. Moreover, adipose cells are much larger than o