Hollywood, Fla. -- Body contouring is based on scientific principles, but an artistic eye and the skill to create symmetry and rounded contour is still needed for an optimal result, said Robert F. Jackson, M.D., who spoke at the American Academy of Cosmetic Surgery (AACS) annual meeting on the application of newer ideas and techniques in breast augmentation and liposuction.
There are four goals that are desired, Dr. Jackson said. The method should be quicker, which reduces anesthesia and risk to the patient; it should be simpler, which reduces surgeon fatigue; there should be improvement in the end result; and, above all, there should be no increase in morbidity or complication rate.
Before breast augmentation, the patient should be fully evaluated, he said. The ideal female contour involves symmetry between the breasts and hips laterally and the breast and buttocks in the anterior and posterior planes. The surgeon needs to appreciate this ideal silhouette and work toward it. "It's a matter of developing the pocket in the right plane so the patient gets the most natural looking breast possible," Dr. Jackson said.
The Spectrum implant, filled posteriorly, gives more fullness and wideness to the base of the breast. This is appropriate for a patient with ptosis. A high-profile implant, on the other hand, works better for a patient with a narrow upper torso and shoulders and who needs more projection and less fullness. "If you give someone with sagginess a high-profile implant, they will sag more. You need a wider base to take up some of the ptosis," Dr. Jackson advises. For patients with wider hips, use a wider based implant to create symmetry between the breasts and hips.
Basics key implant success
Many implants are available, and surgeons need to know their characteristics, such as when an implant is filled, will the base become larger or stay the same. All companies give the dimensions of the base, and the surgeon should measure the patient's breast to determine her base dimensions, he advised.
The AACS Breast Survey added to surgeons' knowledge about choices in breast augmentation. Most surgeons now use smooth as opposed to textured implants because of less rippling and rupture. Also, there is an advantage of saline over silicone. The survey found a 1 percent contraction rate that was greater than a Baker's class 3 for saline implants versus six percent for silicone. Dr. Jackson uses silicone in Adjunctive Study approved patients with severe pectus excavatum and in those with extremely thin overlying tissue. Most surgeons now place implants submuscularly, but Dr. Jackson places them totally submuscularly, i.e., underneath the serratus as well as the pectoralis major muscle. This gives better coverage with less wrinkling and holds the implant in place better, he believes.
Ultrasonic-assisted liposuction came into use in the United States in 1996. Although a very good technique in the right hands, it has some downsides including a long learning curve and the cost of the equipment. There is a possibility of burns and a larger incision is needed.
Clinicians believe the device liquifies fat, making it come off easier and with less bruising and bleeding. But many failed to realize that some of the advantages were the result of tumescent infiltration required with ultrasonic liposuction.
A more safe development
Mechanically assisted liposuction devices came on the market about a year later. Dr. Jackson finds they help him sculpt better and they lessen fatigue. He uses a rotating device. "Mechanical is much safer [than ultrasonic] and you can always switch back to routine liposuction by turning the motor off," he said. Dr. Jackson uses many methods, tailoring them to the particular part of the body or patient.
Rodrigo Neira, M.D., developed a technique of low-level laser-assisted liposuction using an Erchonia laser after tumescent infiltration and found this enmulsified fat and made it come off easier. Dr. Jackson wanted to verify this. "I thought the results were smoother, the fat definitely came off easier and it was more liquefied." His patients also complained of less pain. Dr. Jackson participated in a multicenter study of the laser, and his portion had very good results. "Most of my patients said that the side that I used the laser on hurt less than the non-lasered side." However, the researchers found that the laser had a systemic result, reducing pain in the non-treated, placebo side of the patient as well.
The researchers are now involved in a doubleblind study, where patients treated with a sham laser serve as placebo. Then they receive standard liposuction. With this study about three quarters complete, 72 percent of test subjects meet the success criteria for pain versus 42 percent of those with the sham laser. For ease of fat extraction, the average VAS (a visual analogue scale) rating was under 20 for the test group versus over 70 for the placebo group. Emulsification of fat was much better in the test group as opposed to the placebo group. The score in the test group ranged from 12 to 17 on the VAS, whereas the placebo group was in the 70s--almost a 50 percent difference. For volume of fat removed, there is a clear and sizeable trend with about 20 ml more fat extracted per minute in the test group as opposed to the placebo group. Post-operative swelling is significantly lower for subjects in the test group than for the placebo group.
Sketch before sculpting
In his own practice, Dr. Jackson embraces the Gasparotti technique, combining routine with superficial liposuction and then allowing the skin to contract to enhance the results. Careful pre-operative markings are extremely important. He uses electrical stimulation and ultrasonic therapy post-operatively to reduce lumpiness. Dr. Jackson suggests that tumescent infiltration is the gold standard for liposuction.
Lipo-augmentation and lipo-shifting are new techniques that can be used to smooth irregularities. Fat is aspirated and then placed underneath defects to assure smooth results with no divots. Taping and garments hold everything in place for the first few weeks after surgery to lessen migration of fat.
With superficial liposuction there is greater contracture than with suction only in the deeper layers, he explained. "You need to be superficial, but it needs to be a safe superficial plane. When you hold your patient's new contour in position with garments, the superficial liposuction will allow the tissue to contract. We make small tunnels that are going to scar down. As they do, they pull the skin up and give the tightening and support that is needed to keep the results you have accomplished on the table."
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