Sandra Tagliolatto1, Vanessa Barcellos Medeiros1, Patrícia Cristiane de Sousa Teresani 1, Oriete Gerin Leite1, Janaína Vilela Filipe1, Carla Bassanezi Mazzaro1, Patrícia Accione Rover1, Renata Rita Oliveira Fernandes1
Keywords: LASERS, LIPECTOMY, SUBCUTANEOUS FAT, COLLAGEN
Laserlipolysis is a new technique. The US Food and Drug Administration (FDA) approved the first device for use in sub- cutaneous tissue, the 1,064 nm Nd:YAG laser, in October 2006. The procedure entails applying the laser directly to the adipose tissue in order to melt the fat and stimulate the production of dermal collagen. 1
Laserlipolysis is currently seen as an effective method for removing fat and improving the shape of the body and face. 2 Although not intended as a replacement for conventional lipo- suction 3,4 laserlipolysis offers similar clinical results and has the additional benefit of stimulating cutaneous retraction – skin tightening – and has a fast recovery time, with less pain than the classic technique. 5,6
Laserlipolysis'''''''' mechanism of action is based on the classic principle of selective photothermolysis, in which the energy liberated by the laser is transformed into heat when it reaches its target tissue or chromophores (fat and collagen). Subsequently, the thermolipolysis and denaturation of the collagen fibers occur, with the preservation of the septal architecture, which contributes to the increase in cutaneous retraction. 2 It is impor- tant to note that the use of laser also promotes the coagulation of small subcutaneous vessels, which reduces blood loss and ecchymoses. 1 Additionally, it is important to highlight that the aspiration of the liquefied fat is often carried out after the pas- sing of the laser. 11,16
The fatty tissue''''''''s optic coefficient has been estimated at 400-1500 nm; the irreversible damage to adipocytes appears to be similar in wavelengths of 920-1320 nm. As a result, there are currently a number of lasers with different wavelengths that can be used in laserlipolysis procedures. 7 Many published studies evaluating those different lasers have demonstrated that the removal of small volumes of fat, combined with cutaneous retraction, can be carried out safely and effectively, with the additional benefits of excellent tolerance and fast recovery times. 2,5,8-10
The optimization of the adipocytolysis and the stimulation of collagen fibers depend on the amount of thermal energy accu- mulated in the tissue. This energy is delivered through the slow and sustained application of an internal cannula fitted with fiber optics, which can maintain a local temperature of 40-42º C. 7,11
Histological studies suggest that the benefits of laser inclu- de the destruction of fat cells, the retraction of the skin and a reduction in intra-operative bleeding 12 (Figure 1). Nevertheless, some authors remain skeptical about the high effi- cacy of laserlipolysis, due to uncertainties about the ideal wave- length. 13
With the use of the 1,064 nm wavelength Nd:YAG laser, clinical and histological studies describe a significant contraction in the skin three months after the procedure and an increase in collagen fibers. A coagulation of the blood vessels and lysis of the adipocytes were also observed. 14,15
The efficacy and safety of the 924 nm diode laser (the wave- length that targets fat) combined with the 975 nm wavelength (to provide dermal heating) were evaluated in the treatment of fat reduction and promotion of cutaneous retraction in several areas of the body. High tolerability to the treatment (with minimal and transient side effects such as erythema, ecchymoses and edema) and a high level of patient satisfaction were described. 9
The treatment''''''''s efficacy in decreasing fat and improving cutaneous elasticity, independently of the wavelength used, is described by many authors as being more apparent three months after the procedure. 6,9,14-16
The most frequently observed side effects of laserlipolysis are discomfort, ecchymoses, erythema and edema, all of which resolve in up to one week after the procedure. Patients are usually able to resume their daily activities after 24 hours. 5,15,14 No systemic complications were described in the literature; the few local complications were infections and cutaneous burns. 1,17
This study describes the surgical technique and evaluates the safety and efficacy profile of laserlipolysis in different areas of the body, based on the use of two different lasers, in 120 patients who underwent the procedure over a 7-year period.
A retrospective study was carried out to evaluate the medi- cal records of 120 patients (10 men and 110 women, aged 22- 68) who underwent laserlipolysis at private practices between 2004 and 2010. A 1,064 nm Nd:YAG laser (SmartLipo®, Deka, Italy), was used in 60 cases, while a 964 nm/975 nm diode laser (SlimLipo®, Palomar, USA) was used in the other 60 cases. It is important to note that comparing the two lasers was not one of the study''''''''s primary objectives.
According to the orientation of the manufacturer, in the 1,064 nm Nd:YAG laser, the energy parameters were kept cons- tant (6 W – 40 Hz – 150 mJ), with variations in the amount of accumulated energy. An average accumulated energy of 2000 J per each approximate area of 20 cm2 was kept constant in the subcutaneous region.
For the 924 nm/975 nm diode laser, the parameters (power and accumulated energy) were chosen according to the treated area, ranging from at least 10 KJ of accumulated energy (in the case of small submental fat deposits ) to up to 80 KJ (in the case of large abdomens). In extreme cases, the minimum standards of energy of the 924 nm/975 nm lasers were used (around 10 W/12 W in the case of small submental fat deposits and high parameters – 20 W/20 W – for the larger abdomens. In general, however, the choice of parameters was based on a table supplied by the manufacturers of the equipment. In both lasers, the amount of accumulated energy was adjusted according to the size of the treated area and the patient''''''''s tolerance.
A total of 218 procedures were carried out in different parts of the body. Some patients were treated in multiple areas, however not always in the same surgery. The procedures were distributed as follows: abdomen (28 cases with Nd:YAG laser and 44 cases using diode laser), hips (24 cases with Nd:YAG laser and 30 cases using diode laser), outer thigh (six cases using Nd:YAG laser and eight cases with diode laser), inner thigh (two cases with Nd:YAG laser and six cases using diode laser), infra- gluteal region (two cases with Nd:YAG laser and 12 cases with diode laser), anterior region of the thighs and knees (two cases with diode laser), gluteal region (four cases using Nd:YAG laser and four cases with diode laser), back (six cases with Nd:YAG laser and four cases with diode laser), triceps (four cases using Nd:YAG laser and six cases with diode laser), submental region (ten cases with Nd:YAG laser and 12 cases using diode laser), gynecomastia (two cases with diode laser), lower eyelids (two cases with Nd:YAG laser) (Graph 1).
All patients submitted a detailed medical history and were asked about comorbidities and their use of medications. The fol- lowing laboratorial tests were requested: complete blood count, coagulogram, hCG, fasting plasma glucose test and protein electrophoresis when appropriate; specific examinations were conducted in particular cases, such as viral serology, cholesterol and triglycerides, renal and/or hepatic function, abdominal ultrasound,cardiological evaluation, etc.
A term of informed consent and pre- and post-treatment guidance were supplied to the patients. These documents explai- ned the procedures and instructed patients on the use of medi- cations (prophylactic antibiotics and analgesics, if necessary), compressive garments , and the need to limit sun exposure and rigorous physical activity. It also described the expected recove- ry process.
All patients were weighed, measured and documented photographically, with the demarcated areas under the same illumination and positioning parameters.
The procedure was carried out in an outpatient operating room. Each patient was fitted with a pulse oximeter to monitor vital signs, and had his or her blood pressure taken before, during and after the procedure.
In all cases, the anesthetic point and subsequent micro- puncture were carried out using a number 15 scalpel blade in the most appropriate site in order to allow good access to the demarcated area. All procedures used Klein''''''''s tumescent anesthe- sia (1,000 ml of 0.9% saline solution + 1 ml of 1/1,000 epi- nephrine + 25 ml of 2% lidocaine without vasoconstrictor + 10 ml of 10% sodium bicarbonate), injected through infusion pump, controlled for maximum volume according to the patient''''''''s weight. 18 The highest volume of Klein''''''''s anesthetic used in our cases, was 2,000 ml, which is below the maximum dose of 35 mg/kg used when liposuction is performed. 18
The preparation of the laser – assembly of fibers and adjus- tment of parameters – was adjusted for each patient, while wai- ting for the anesthesia to take effect.
After obtaining local vasoconstriction with the tumescent anesthesia, the fiber optic microcannula was inserted in the sub- cutaneous in the same micropuncture as the anesthesia. The can- nula was then slowly moved forwards and backwards, promoting a uniform distribution of energy in the treated area. Cutaneous temperature was monitored using an external optic thermometer.
When the established parameters were reached and the fat was felt to "soften" in the treated area, the application of the laser was halted. In most cases, the melted fat was aspirated using thin liposuction cannulas and low pressure, with a fluid fatty substance being observed; in general there was less bleeding and, consequently, greater ease in removing the fat. It is impor- tant to note that the decision about whether to aspirate was based on each patient''''''''s psychological characteristics and amount of excess fat, and their degree of urgency for results. In patients with cutaneous sagging without considerable amounts of loca- lized fat, no aspiration was carried out after the laser application.
In each patient, the remaining accumulated liquid was drained from the subcutaneous up until the insertion puncture and the wound was sutured. At the end of the procedure, a com- pression bandage was applied at the site of the puncture and the patient was discharged if accompanied.
After 24 hours, all patients had resumed their routines, except for those that involved vigorous physical activity or sun exposure. They were instructed to use commercially available compressive garments made for specific parts of the body for two weeks (submental region) to four weeks (abdominal region, hips and outer thighs). After seven days they returned for the first photographic evaluation and the removal of sutures.
Drainage and use of 3 Mhz ultrasound (Manthus ®, KLD) in the post-operative period were recommended, and the follow- up visits were scheduled (for seven days, and one, two, three and six months). The follow-up visits were aimed at monitoring the regression of the inflammatory process (marked by edema and fibrous areas), and the gradual improvement of the body contour through clinical examination and standardized pictures.
Patients (n = 120) were treated between 2004 and 2010; 218 procedures were carried out in different areas of the body. The areas that underwent laserlipolysis most frequently were the abdomen, hips, infragluteal region, outer thighs and submental region (Graphic 1).
In the subsequent follow-up visits, a significant reduction of fat and the correction of the contour and retraction of the skin were observed in the treated areas in the clinical examina- tions and comparison of pictures. Most patients expressed satis- faction with the outcome in the first follow-up visit, with the number of positive feedbacks increasing in the following months – especially after the third month, when improvement was observed in all patients (Figures 2, 3, 4, 5 and 6).
Regarding adverse effects, no scars, infections, hypo or hyperpigmentation were observed. Edema and ecchymoses (with spontaneous resolution in one to four weeks) were observed in all patients, in different intensities and proportionally to the procedure''''''''s magnitude. Small areas with fibrosis (which resolved spontaneously or after the use of local ultrasound) were observed in most patients in the first months after the procedure.
Ninety percent (108 patients) were satisfied with the results (Graph 2). All 12 patients who expressed dissatisfaction nevert- heless described some degree of improvement. Of the dissatis- fied patients, it was concluded that in four cases, liposuction should not have been recommended, due to the excess fat and sagging of the skin. The patients'''''''' psychological profiles were not favorable to the type of procedure in three cases. In the remai- ning five cases of dissatisfaction there were unrealistic expecta- tions regarding the technique and the results after a single appli- cation (Graph 3).
Except for four cases, complementary procedures were car- ried out using the same technique, with improvement of the final outcome. The use of complementary techniques, such as a low potency diode laser (Tri-active®, Deka, Italy) or radiofre- quency (Reaction®, Viora, USA) was suggested in two cases, with improvement in the final outcomes. Two of the patients who were dissatisfied with the final outcome did not attend the follow-up. Finally, it is important to note that the number of patients dissatisfied with the procedure''''''''s outcome was similar between the two lasers used.
The laserlipolysis application technique requires specific training and constant attention in its execution, and when car- ried out carefully usually reaches its objectives, providing physi- cians and patients a high degree of satisfaction. 9,15,17
The two devices used in this retrospective study were shown to be effective and safe. However, peculiarities were observed between them. For example, the 924 nm/975 nm diode laser''''''''s fiber optic cannula is more flexible and facilitates the execution of the procedure, but it cannot be reused, which increases the cost of the procedure.
Although there are few studies on laserlipolysis in the lite- rature, the technique has demonstrated results similar to those of conventional liposuction in several areas of the body. The advan- tages of this new technique are: the promotion of cutaneous retraction, a shorter recovery time and less physical exertion for the surgeon, since the thermal action makes the sliding of the cannula easier. 9,13,19 The decrease in post-operative trauma is probably associated with the capacity of coagulation of the small vessels of the adipose tissue and the smaller diameter of the can- nulas used in the procedure. 19
The findings of this study are in line with data found in the literature regarding the degree of satisfaction with laserlipolysis. Katz and colleagues1 evaluated 537 laserlipolysis procedures and concluded that it is a safe and effective technique for the remo- val of localized fat. DiBernardo4 found statistical significance in the superiority of the cutaneous retraction obtained using laser- lipolysis compared with conventional liposuction.
It is also important to highlight the absence of systemic or serious complications in the cases studied, as well as a lack of other adverse effects that are typical of lasers, such as burns, blee- dings or infections – which also supports the findings in the lite- rature. 1,5,15-17
This technique''''''''s efficacy and safety seem to be correlated to the amount of accumulated energy in the target tissue and, consequently, to variation in the local temperature, which must be kept constant at 40-42º C. 7,11,13,14,17
Further studies regarding the definition of the ideal final tem- perature will help achieve better results with laserlipolysis, a proce- dure that already provides a high degree of patient satisfaction.
Based on our accumulated experience with the use of lasers in laserlipolysis treatments and the related literature, we can assert that laserlipolysis is an effective and safe procedure to be used in the reduction of localized fat and cutaneous retrac- tion treatment.
A precise surgical indication and the correct orientation of the patient regarding the technique and its limitations are fun- damental for a high degree of satisfaction among physicians and patients.
Further prospective controlled studies on laserlipolysis are necessary to improve the technique and optimize the parameters in order to increase the efficacy and safety of the procedure.
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