Body Contouring and VASER Technology, the Fourth Dimension

Abstract

Body contouring surgery encompasses several facets. However, it is only in the last 15 years that body-sculpting technology has been incorporated in body contouring on a larger scale. This has added further refinements to the aesthetic outcomes of body contouring surgery. Advances in VASER technology meant it has become synonymous with the art of lipo-sculpture, body sculpting and body contouring. When performing body contouring, the first step in liposculpturing the tissues is to emulsify the fat using ultrasound resonance. The emulsified fat is then aspirated with a power-assisted suction device, and in appropriately selected patients, surgically excising the skin excess to achieve the desired results. It is important not to forget the other added bonuses of VASER technology, which includes reduced surgeon’s fatigue, enhanced skin retraction and reduced downtime; all being achieved at a high safety margin. Body contouring does not stop at emulsifying fat and aspirating it. Fat transfer in the selected patients has become an integral part of body contouring surgery. This includes patients wishing breast augmentation and buttock augmentation utilising their own fat, thereby reducing any concerns they may have with using silicone-based implants, whilst achieving cosmetically pleasing long-lasting outcomes. Surgical excision where technology cannot overcome skin excess and laxity adds to the aesthetic outcomes in selected cases, thus bringing to fruition the hybrid surgical approach popularised in the twenty-first century. One example of many is incorporating VASER lipo-sculpture with abdominoplasty.

1. Introduction

Contouring is defined as the action of changing the shape of something [1] (Cambridge English Dictionary). However, in a Plastic Surgeon’s eyes, it is the action of forming and shaping new cosmetically pleasing contours of the body or face. In doing so, thus recreating and restoring the desirable anatomical relationships nearest to the golden ratio of beauty yet respecting the racial differences of beauty.

One of the great doyens of Plastic surgery, Ivo Pitanguy defined body contouring surgery as a collection of procedures with the goal of volumetric manipulation of superficial tissue, normally the adipose tissue, with or without removal of skin excess [2].

In our opinion, body contouring is the foundation of recreating beauty by moulding tissues, proportioning contours and removing excess, be it fat and/or skin when applicable. This recreates positive ‘spaces’ (light reflection) and negative spaces (shadows) when warranted and where desired (Figure 1). We must always remember that the patient’s realistic goals and aspirations must be an integral part of our plans in achieving the best results.

Figure 1.

Forty-two-year-old male who had undergone high-definition body sculpting with VASER. The lipoaspirate was 4.4 litres.

Although technologies have added to the outcomes in body contouring, it is of profound importance to remember that it is unlikely to replace surgery in entirety and certainly not for the near foreseeable future. However, it will remain a powerful adjunct to surgery raising the bar to achieve consistent good outcomes in body contouring especially when using the hybrid approach.

The expectations of the human body-form appearance in both sexes have changed over the last five decades. This evolution is in continuous flux and in our opinion, is heavily influenced by factors including social media and designs of attire. This adds significant peer pressures to both patient and plastic surgeon alike.

Peer pressure on the surgeon has its drawbacks, but also has its benefits. One such important benefit is driving advances in our speciality in safe surgical techniques and technologies. This spurs on the medical technology companies influenced by market forces to continually respond to the demands of the plastic surgeon based in part on patient’s aspirations.

2. Technologies in body contouring

The technology in body contouring continues to evolve. The devices on the market are numerous; however, as the chapter is designated to talk about VASER technology, body contouring and the hybrid approach, hence, we will concentrate our writing on this technology, its role and relationship with surgery in body contouring.

What does VASER stand for? It is an acronym, which stands for ‘Vibration Amplification of Sound Energy at Resonance’. Certainly, a scientific mouthful, which practically can be simplified through describing its action in plain English. The ultrasound waves break up and liquefy fat cells making it easier to remove by liposuction at lower pressures with ease and more abundance than with traditional methods. In doing so reducing surgeon’s fatigue yet safely achieving consistent aesthetic outcomes, thus popularising this type of body contouring surgery (Figure 1).

3. The evolution of VASER

Ultrasound-assisted liposuction (UAL) broke down fat cells to produce an emulsion, leading to a less traumatic aspiration of fat. Unfortunately, early on high incidence of burns, skin necrosis and scarring occurred [3, 4].

The development of hollow probes rather than the earlier solid probes although meant less risks; however, the high energy delivered meant when used near to skin; burns, scarring, waviness and contour irregularities could occur [3, 4].

The first report of clinical application of a third-generation ultrasound liposculpture device, which used pulsed low-power ultrasound and high-efficiency small-diameter solid titanium probes; VASER liposculpture was reported by Jewell et al. [5]. The energy was much less and the pulsed mode reduced heat generation, thus reducing risks and potential complications.

The advent of VASER meant plastic surgeons elevated liposuction to new highs, and VASER-assisted liposculpture (VAL) became popularised. Alfredo Hoyos embraced this technology from an early stage and pushed the boundaries to new levels [6].

With these advances was born new nomenclature formulated to describe the complexity of the detailed sculpting of the superficial fat and deep fat over muscles and in between muscles VAHDL [7].

4. The evolution of fat transfer

Fat grafting and lipofilling are synonymous with fat transfer. In this chapter, we will use the term fat transfer, as in our opinion it is more fitting as a descriptive term than either of the other two; however, the words may be used interchangeably.

Fat transfer was first documented in 1889 when omental fat was grafted between the liver and diaphragm to repair a diaphragmatic hernia [8].

In 1892, Neuber et al. described fat taken from the forearm and transferred to fill a volume and contour irregularity of the face caused by a scar with excellent results [9].

In 1895, Czerny et al. transferred fat from a lipoma of the back for breast reconstruction [10].

The first needle and syringe fat transfer was demonstrated by Brunning et al. in 1911 when he injected for the first-time fat subcutaneously in the nose to correct the aesthetic result following rhinoplasty. Brunning was the first to identify that fat resorption meant the results were not sustainable [11].

Refinements of the fat transfer did not occur until 1975 when the Fischers, father and son, developed the modern techniques of liposuction using metal cannulas [12].

Further advancements in liposuction and fat transfer techniques occurred when in 1992 Coleman proposed a new method of harvesting fat, which minimised trauma to adipocytes [13].

In 1993, Klein added the Tumescent technique which made harvesting fat easier and less traumatic to the adipocytes with less blood loss making large volume fat harvesting possible with a higher safety margin; this popularised large volume liposuction [14].

In our opinion, with the advent of safer large volume fat harvesting, it was only natural that the collected fat ought not go to waste, hence paving the way to large volume fat transfer.

5. Fat donor and recipient sites, our experience

In this chapter, we will consider the donor sites we commonly harvest fat from and the recipient anatomical sites we transfer fat to. In our series the recipient of fat most common anatomical sites included the face, breasts, and buttocks. This parallels what is documented in the world literature [15].

Our choice of fat donors site/s depends on a number of factors including the amount of fat required, the anatomical area we plan to transfer the fat to, and the anatomical location/s where fat is available especially in the thin patient. We must respect that in harvesting the fat; the donor site/s aesthetic outcomes are appropriately proportioned.

Since we started liposculpturing the body’s different anatomical sites with Vaser, it has become much easier to make available the amount of fat required to transfer to breasts and buttocks when other less advanced methods fail at worst or at best may not achieve this in one stage. In our experience, this is not so for the face as the volumes required are relatively small and, in most cases, available even with less advanced technology. In the face and in the majority, we tend to use syringe-assisted lipo-aspiration to harvest the fat for transfer.

6. Face contouring

When transferring fat to the face or anatomical areas of the face, we tend to use submental fat if available (Figures 2–4), including when performing a facelift. In the case when submental fat is of limited availability, then we use abdominal fat.

Figure 2.

Twenty-nine-year-old male 7 months following VASER liposuction of neck and 6 cc fat transfer of fat to chin.

Figure 3.

Thirty-four-year-old male 3 weeks following submental and neck liposuction in addition to buccal fat removal. An 8 cc fat transfer to chin was also performed.

Figure 4.

Twenty-eight-year-old female 1 week following neck liposuction, buccal fat removal and 2 cc fat transfer to chin.

In the case of fat transfer to breasts and buttocks, we use the abdomen, lower back and thighs. The thighs are used as a backup unless the preoperative plan included them as a part of body contouring.

In the face and in selected patients, fat transfer can be used as a sole method of facial rejuvenation instead of dermal, Hyaluronic Acid, fillers (Figure 5). Fat can also be used an adjunct to face and midface lift surgery, thus adding further refinement to the cosmetic outcomes.

Figure 5.

Fifty-one-year-old female 5 months following 24 cc of fat transfer to face.

Fat is injected in key areas of the face including the temples, zygomatic area/cheeks, midface, nasolabial folds, lateral cheeks, pre-jowl sulcus, marionette lines and jawline. The glabella, brows and forehead are also targeted sites for fat transfer in selected patients (Figure 5). Our plans when transferring fat into the face or any of its anatomical areas mirror, the techniques we use when injecting hyaluronic acid dermal fillers in the ageing face (Figures 2–4).

When transferring fat to the face, we methodically target the different planes injecting different consistency of fat in the different compartments, both the superficial and deep fat compartments [16], in addition to depositing the fat on the bone when required.

Our non-surgical dermal fillers experience in injecting the face contributed to us pushing the boundaries with our fat transfer techniques further adding to the aesthetic outcomes of our patients.

We developed a simple formula relating to the amount of fat required to be transferred in face rejuvenation. One millilitre (1 cc) of hyaluronic acid filler equates to 2-3 cc of fat irrespective of age or anatomical area.

However, we must keep in mind that fat does not have the same lifting properties as hyaluronic acid and different anatomical areas require different consistency of fat and viscosity. One such example is Nano-fat in the tear trough and lower eyelids area [17]. We use mechanical agitation to obtain this type of fat following its harvest.

In the twenty-first century, we feel that using high-definition ultrasound is likely to be the next step in progression when transferring fat into the face, thus aiding the accurate placement of fat, helping to avoid blood vessels, thus further reducing risks.

7. Abdominal contouring

Our algorithm for abdominal contouring is simple. It pivots on four determining factors.

The first factor is the skin quality, laxity and excess. The second the rectus sheath its weakness, bulge, divarication and any hernia/s. The third is fat, its excess and distribution. The fourth is patients’ aspirations and whether they are achievable, if so, how best to achieve them safely and efficiently.

If the skin quality is poor with laxity and significant excess, then a surgical excision is warranted (Figure 6). If the rectus sheath shows weakness with bulge and divarication, a plication is required. If a hernia is detected on ultrasound prior to surgery, then a multidisciplinary repair of this hernia with a general surgeon is planned.

Figure 6.

Forty-nine-year-old female 6 months following VASER liposculpture to abdomen and flanks with abdominoplasty and plication of the rectus sheath. She also had bilateral breast reduction with fat transfer to upper poles to improve upper pole fullness.

Fat excess warrants liposculpture; however, the fat distribution influences the way we create curves and the time it takes. Patients’ aspirations will have an influence on us as plastic surgeons; however, we must respect the confines of what is scientifically achievable within the realms of safety yet obtaining the best aesthetic results.

We must on occasions when a patient has unrealistic expectations protect that patient by being honest with them. Although we let them down gently, however, we will offer them the reasoning as to why and the support required.

Abdominoplasty with rectus sheath plication is a common procedure. Our aspirations and goals are to push the surgical outcomes of abdominoplasty to new heights. This is achievable when the aesthetic results of surgery; significantly outweighs the size of scarring whilst creating the desired contours and appropriate proportions. To do so, an open mind utilising a hybrid approach must be contemplated (Figures 7 and 8).

Figure 7.

Forty-three-year-old female 6 months following 360 VASER liposculpture of abdomen and flanks with first stage fat transfer to breasts. Followed by a second stage VASER liposculpture of thighs and back.

Figure 8.

Forty-three-year-old female 6 months following 360 VASER liposculpture of abdomen, and flanks with first stage fat transfer to breasts. Followed by a second stage VASER liposculpture of thighs and back.

As plastic surgeons we aspire to always better our surgical outcomes and improve safety. Understanding the abdominal vascular territories and blood supply meant we could incorporate liposculpture with surgical excision yet reduce surgical complications [18].

VASER has added a safety margin to abdominoplasty as it produces less traumatic fat removal from the abdominal flap, thus decreasing the chances of complications associated with lipo-abdominoplasty [19].

Suction-assisted liposuction does not impair the regenerative potential of adipose-derived stem cells [20]. As the lipo-aspiration pressures are much lower following VASER than traditional liposuction, this also reduces risks to the skin [21].

The Vent-X, which is the vacuum pump designed to work with VASER, the vacuum it generates ranges from 0 to 760 mmHg. The dial starts at zero and goes all the way to 30. If we are to perform lipo-aspiration with fat transfer in mind, then we set the dial at 10–12, which equates to a third of atmosphere, ~250 mmHg. In doing so, we protect the skin and the harvested fat [21]. VASER also reduces surgeon’s fatigue as the more fluid fat the easier it is to aspirate.

The time it takes from fat harvest to fat transfer has a bearing on the retention of fat in the recipient site. The shorter the time, the better the uptake with a critical period of 2 hours [22]. With VASER making fat harvest more time-efficient, this could further aid in better fat retention.

We must consider whether there is a limit of the lipoaspirate volume when performing an abdominoplasty; however, overall, the literature appears to support that current limits on liposuction volumes in lipo-abdominoplasty are arbitrary and do not reflect valid thresholds for increased complications in the hands of an experienced plastic surgeon [23].

8. Breast contouring

Accepting when we think of the word breast/s contouring does not normally stem to mind. When talking about breast contouring in the majority, we tend to focus on augmentation, reduction, mastopexy and mastopexy augmentation. However, if we go back to the basics, the word contouring is to change the shape of something, hence by changing the shape of the breast/s we are effectively contouring them [24, 25, 26].

Fat transfer to the breasts has become popularised following a change in the views about its safety by the American Society of Plastic Surgeons in 2009. It was more than two decades when they condemned this procedure due to fear that it may obscure the detection of breast cancer [24, 25, 26].

In this section, we will focus on breast contouring and fat transfer in the context of autogenous augmentation, mastopexy augmentation, asymmetry correction, and volume replacement (Figure 9).

Figure 9.

Thirty-year-old female. She had VASER liposculpture to abdomen. She had 340 cc of fat transferred to right breast and 220 cc to left breast for the purpose of asymmetry correction and augmentation.

The hybrid approach, which includes silicone implants with fat transfer, will also be considered. In selected patients, fat transfer is performed at the same time as breast reduction surgery; thus, adding fullness to the upper poles and cleavage of the breasts (Figure 6).

We must accept that not all patients desire one or the other treatment/s and fat is not always available to achieve the goals set out in the agreed pre-treatment planning schedule.

Considerations when injecting fat in the breasts include targeting the subcutaneous space and pre-pectoral plane, in addition to the breast tissue. Respecting the views of others and their practices, however, we do not see a case for transferring fat into or under the pectoral muscles and feel that this could add unnecessary risks without necessarily improving the aesthetic outcomes.

It is important to keep in mind that the pre-operative breasts’ volume has an influence on the volume that ought to be transferred. Hence, it is important to appropriately counsel the patients prior to treating them as fat resorption will occur and can vary between 30 and 70% of the transferred volume within 12 months of transfer [27].

In females who are undergoing fat transfer to the breasts, we include a routine mammogram as a baseline in patients ≥40 years of age. As an added safety net, we routinely perform abdominal ultrasound screening if we are using the abdomen as a fat donor site to exclude any clinically undetected hernias and rectus sheath pathology or abnormal anatomy.

Surgical fat transfer techniques include three steps, fat harvest, processing the harvested fat and finally injecting it into the breast/s [28].

The volume of fat required influences the technique for fat harvesting. Early on we used a syringe-based mechanical aspiration of the fat and the Coleman centrifuge [29].

However, we now use Vaser for the larger volume fat harvest with a 3.7 mm cannula. Our technique includes allowing the aspirated fat to self-separate over a period of 30 minutes rather than spinning it with centrifuge, as we believe this reduces the trauma to the harvested fat.

The fat is then injected into the breasts using a 10 cc syringe and 2 mm cannula. For further refinement, a 5 or 1 cc syringe can be used when required.

Although the literature supports the view that when using the larger harvest cannula, the more fat survives. Nonetheless, a balance must be struck between cosmetic outcomes and scarring extent [30].

Our experience tells us like others that the less we handle the fat, the better is the survival rate when transferred into other tissues [31].

It is important to add that it is best to transfer the fat without significant time delay from the time it was harvested and to use a closed system when harvesting the fat with the least exposure to air [32].

The fat must be infused with small volume injections and distributed in different levels of the breast with the least traumatic method using a retrograde injection technique to minimise injections into vascular spaces. We aspire to limit the fat transfer volume per breast to 250–300 cc (Figures 6 and 7).

If larger volume of fat is required for transfer in a small breast, then pre-surgery external expansion is recommended [33]. However, in our practice and contrary to the experience of others we find uptake and acceptance for this method of external expansion amongst our patients thus far has been very limited.

9. Gluteal contouring

Contouring the gluteal area is synonymous with the Brazilian Buttock Lift (BBL). Fat has gained popularity in its use, as a method of adding volume to the gluteal area becoming one of the fastest growing procedures in aesthetic surgery, and it is often performed as an adjunct to body contouring [34]. In 1987, Toledo presented one of the first studies investigating fat transfer in buttock augmentation in the USA [35].

To reduce the risks associated with injecting fat in the buttocks, we inject the fat above the muscle using a 5 mm cannula approaching in an acute angle. This angle of approach makes it more difficult to penetrate the deeper gluteal muscles layer.

When transferring fat to the buttocks, it is of paramount importance to utilise handheld high-definition ultrasound to determine the plane and depth of injection.

In our practice, we do not utilise silicone implants to contour the buttocks as we see fat transfer to be a more practical and safer option when performed by appropriately trained Plastic surgeon/s [36].

In our opinion and the collective opinion of others, fat transfer is the gold standard for gluteal augmentation, as we feel it gives a natural look to the gluteal area with high patient satisfaction [37].

The procedure has been made even safer with the advent of handheld high-definition ultrasound, which gives a visual on the anatomical location, and depth of the transferred fat into the buttocks, thus avoiding the gluteal muscles and reducing risks of embolus and vascular origin complications [38, 39, 40, 41].

In our practice, VASER is used when harvesting fat for BBL. BBL is usually the final stage of 360-body contouring. For simplicity of description, we had attributed the terminology the fourth dimension for this combination of surgery (Figure 10).

Figure 10.

Twenty-four-year-old female. Six months following VASER 360 liposculpture of abdomen, flanks and back with 800 cc fat transfer each buttock area, Brazilian butt lift (BBL).

The reason of leaving BBL to the end of the sequence of operative procedures is for avoidance of the patient being on her buttocks for the duration of a relatively lengthy surgery, thus avoiding unnecessary pressure on the transferred fat.

10. Patient selection

The criteria of patients’ selection for body contouring are unchanged from our last published chapter in Enhanced Liposuction New Perspective and Techniques 2022 [42]. However, when we are considering fat transfer be it for breasts, abdomen or gluteal region, we take into account four criteria.

For the sake of clarity, we have listed these criteria as anatomical structures from the most superficial tissue layer to the deepest.

These criteria include:

1. Skin, quality, laxity, excess and distribution.

2. Fat, deep and superficial, which is below and above Scarpa’s fascia, respectively.

3. The deep fascia and muscles.

4. Surface anatomy and relationship with deep structures.

Why is this important to us?

The skin plays a major role in outcomes. For example, if the skin quality is poor, then the skin may need further non-surgical tightening, one example is the use of monopolar radiofrequency. In our practice, we use INDIBA Deep-care as our monopolar radiofrequency device of choice for its ease of use with very low risks and almost non-existent downtime. If the skin has significant excess, then surgical removal is warranted, examples are mastopexy and abdominoplasty.

The liposuction of the deep fat is for the aim of debulking the envelope; however, liposuction of the superficial fat is for sculpturing it to re-create shadows and light reflections to a near perfect body contouring. When adding volume in the relevant space/s, we create the fourth dimension.

11. Patient safety

How do we uphold the highest safety levels when considering patients for body contouring including VASER liposculpture, fat transfer and excisional surgery?

This starts with patient selection and the appropriate surgery in addition to having the relevant instrumentations. Accurate planning is a prerequisite for successful cosmetic surgical outcomes. Precise meticulous execution of the surgical plan is paramount in achieving the best aesthetic outcomes.

Let us not forget in this equation that the surgeon’s and team safety is equally as important as the patient. One simple example is the distance the surgeon’s arm travels when performing a large volume liposculpturing procedure.

We calculated the distance travelled in 4–5 hours of 360-body contouring procedure could be in the region of 10 miles; however, if the height of the table is adjusted by few centimetres, this could reduce the distance the surgeon/s hand and upper limb travelled by ~25%.

One must remember that a surgeon’s journey is 20–25 years in practice, and this type of surgery weighs heavily on his/her joints of the hand and upper limb in addition to the neck. Hence, one must protect the surgeon and the team as they experience the same stresses on their physique during such time intensive surgery with high concentration levels, and the environment must be relaxing and harmonious.

12. Summary

Selecting the right patient for the relevant procedure, using the appropriate instrumentations whilst having the necessary skills and expertise, is of profound importance. Additionally, it is a must to have a well-trained, cohesive team, which functions at the highest levels of governance.

These two factors will further contribute to patients’ safety and good surgical aesthetic outcomes, whilst minimising risks and potential complications.

On the one hand, such provision of service must have at its foundation an ethical patient-centred approach.

On the other hand, aspiring to the continuous development of the team involved in the patient journey from the first point of contact and until discharge is of profound importance. This is the ethos on which we have built our practice.