Definition Laser-Assisted Liposuction: Personal Technique

Abstract

Body contouring by fat removal undergoes constant improvement, evolution, and refinement. The treatment of the superficial layer of subcutaneous tissue promotes better skin retraction in specific locations and more defined and natural outcomes, whether in the abdomen or other body parts. The evolution of these procedures and the improvement in surgical technologies decreased complications, leading to safer surgeries. Laser is one of the technologies assisting liposuction to promote better skin retraction. The present retrospective study of medical records of 218 patients operated on by the author in 241 procedures using laser-assisted definition liposuction, with wavelengths of 915 nm and 980 nm, assessed the clinical outcomes, the level of patient satisfaction, the complication rate, and the need for reoperation. In the current case series, laser-assisted definition liposuction, especially using 915-nm and 980-nm wavelengths, was a feasible and reproducible technique to improve body contour and muscle definition. The incorporation of laser has shown itself to be an alternative within the surgical arsenal to enable the achievement of the objectives of the indication.

Keywords

abdominoplasty - body contouring - laser therapy - lipectomy - technology

Introduction

Body contouring by fat removal undergoes constant improvement, evolution, and refinement. Since the 1970s and 1980s, Schrudde[1] [2] published the use of a curette for lipectomies in the lower limbs. Next, Illouz[3] published his experience using blunt cannulas with holes for fat suction, and other authors followed his path. In 1985, Hakme et al.[4] described mini-abdominoplasty with a liposuction technique, resecting excessive skin from the suprapubic region in selected cases. In 1996, Pinto et al.[5] described superficial liposuction as significant for better skin retraction. In 2001, Saldanha et al.[6] published their lipoabdominoplasty technique, consisting of a detachment of the wide abdominal flap through liposuction to spare its perforators and minimize the complications of classic abdominoplasty.

In recent years, there were technological advances in the field of liposuction, with an emphasis on ultrasonic liposuction, vibroliposuction, and laser lipolysis, benefiting patients by a better definition of the abdominal muscles, avoiding the flat abdominal appearance and reducing tissue trauma and bleeding, and, for the surgeon, facilitating the surgical procedure, reducing downtime (that is, the period of liposuction system interruption), promoting skin retraction, and enabling the application in the fibrous areas of scars.[7] [8] [9]

Liposuction-related complications include bleeding, unesthetic outcomes, thromboembolism, skin irregularities, prolonged edema, ecchymosis, hyperpigmentation, sensory changes, seromas, hematomas, ulcers, necrosis, visceral perforations, systemic infection, fat embolism, sepsis, and death. The estimated mortality rate for liposuction is of 1 in every 5 thousand procedures.[10] The introduction of minimal-trauma techniques, intraoperative and postoperative (PO) care, less traumatic cannulas, local anesthetics in tumescent techniques, thromboembolism prophylaxis, compression garments, and safety criteria reduced liposuction-related complications.[11]

Abdominal and body contouring liposuction is mainly indicated for subjects of any gender who are dissatisfied with excessive localized fat accumulations not eliminated through diet, physical activity, or other tactics, and for the correction of lipodystrophies, imbalance in the distribution of congenital or acquired, partial or generalized fat, and as an adjuvant procedure in gender reassignment or obesity treatment. It may be performed isolatedly or in association with other surgical procedures, respecting the recommended safety standards.[12]

The surgical procedure consists of the aspiration of fat using cannulas attached to a vacuum syringe or to liposuction, vibroliposuction, or ultrasonic devices. In the classic, first-generation abdominal liposuction deep layer aspiration is recommended, usually leaving a fat layer throughout the abdominal wall, that is, the subdermal fat, which minimizes irregularities. With the traditional technique, it is hard to achieve the goal of definition and improvement in the esthetic appearance of the abdominal muscles, since subdermal fat hinders the visualization of muscular details.[13]

From an anatomical point of view, subcutaneous adipose tissue stores energy, protects against mechanical shocks, enables mobility over deep structures, provides thermal insulation, and has a cosmetic effect by shaping the body contour.[14] Several authors[15] [16] [17] organize the abdominal wall into the following layers: skin (epidermis and dermis), superficial or areolar adipose tissue (SAT), horizontal fibrous connective tissue (membranous layer or fascia superficialis), deep or lamellar adipose tissue (DAT), deep fascia, and abdominal wall muscles. The DAT covers the deep fascia and abdominal muscles, presenting variations in thickness, adipose content, and mechanical resistance among subjects. It is thinner in areas with fibrous layer attachment (inguinal ligament, linea alba, and bony prominences). The oblique distribution of the septa, the limited properties of elasticity to stretching, and low resistance to compression explain the sliding of this subcutaneous tissue over the deep fascia. The DAT is present in the abdomen, flanks, trochanteric region, inner part of the upper third of the thighs, knees, and back of the arms. Studies have highlighted that the distribution of SAT and DAT (superficial fascial system) varies in different body areas, according to the subject, weight, and gender. It is based on these observations that surgeons come across people who arrive at the plastic surgery office claiming to be athletes but, despite practicing physical activity, cannot achieve the definition of the abdominal muscles and the desired esthetic appearance.

The superficial liposuction technique, first reported by Illouz[18] to improve the appearance of the infragluteal fold, was developed to refine the skin fold or groove using a thin cannula. However, it often causes sequelae, such as persistent grooves and irregular contours.[13] [18]

In 1993, Mentz et al.[13] published a study on high-definition liposuction, the third generation of liposuction procedures, for athletic men who could not define their abdominal muscles through bodybuilding. They called it abdominal etching and performed the procedure in the anterior abdominal wall alone and in patients with less than 15% of body fat. In 1997, Ersek and Salisbury[19] proposed a specific cannula design for superficial liposuction.

In 2003 Hoyos (apud Cipriani, 2015[20]) presented an improvement in the technique described by Mentz, expanding its use to simulate the muscles of the abdomen, back, flanks and legs, pectorals in men, and glutes in women, and called it high-definition liposculpture (HDL) or high-definition liposuction. Although it was a technical advancement, it required surgical training, was exhausting for the surgeon, and was painful and traumatic for the patient, with slow recovery and prolonged edema. In 2007, Hoyos and Millard[21] published the association of Vibration Amplification of Sound Energy at Resonance (VASER), which uses ultrasonic technology for gentle liposuction, to high-definition liposculpture.

Apfelberg et al.[22] published studies on laser lipolysis from 1992 to 1996 for indications similar to those of tumescent liposuction. The procedures apply neodymium-doped yttrium aluminum garnet (Nd:Yag) laser inside the liposuction cannula. Widely used in Europe and Latin America, laser lipolysis (also called laser lipoplasty) was introduced in North America in 1994,[9] [23] and it was approved by the United States Food and Drug Administration (FDA) in October 2006.[24] [25] In 2018, Motta[26] published his work using diode laser at the wavelengths of 915 and 980 nm in high-definition liposuction. The advantages of this technique include lower levels of surgical trauma and blood loss, which results in lower levels of pain, bruising, edema, and shorter recovery time.[26] Several laser types with different wavelengths have been used in laser lipolysis with a low complication rate, and it is critical to study their outcomes.

Objective

The current study aimed to evaluate the outcome of the use of diode laser at the wavelengths of 915 and 980 nm laser-assisted definition liposuction procedures in a case series.

Materials and Methods

The present is a a retrospective study of medical records of patients operated on by the same surgeon in different hospitals in the town of São José do Rio Preto, state of São Paulo, Brazil, from 2014 to 2023, using the laser-assisted definition liposuction technique and the diode endolaser (Delight, Vydence Medical), at 915-nm and 980-nm wavelengths. Initially, the procedure used mechanical aspiration and, starting in 2020, it employed a vibrational aspiration device, a 4-mm diameter cannula with 5 Mercedes-type orifices with 30 or 35 cm in length. All patients (or their legal guardians, in cases of underage subjects) signed the preoperative informed consent form and the image authorization form for surgical outcome disclosure. The minimum PO period for data collection was of 6 months.

The inclusion criteria were patients of any gender, over 16 years old, submitted to medium- and high-definition laser-assisted liposuction using a diode laser to treat adipose tissue irregularities in the body contour of the trunk (abdomen, chest, flanks, and back), with a body mass index (BMI) < 35 kg/m², classified as thin, regular, overweight, or obese, with preoperative tests (blood count, coagulation tests, blood sugar level, serology for human immunodeficiency, hepatitis B, and hepatitis C viruses, simple urine test with culture and sensitivity, electrocardiogram, chest X-ray, and abdominal wall ultrasound) within normal parameters, and with low cardiological risk.

The exclusion criteria were patients with coagulation disorders, decompensated cardiovascular diseases, hypertension, diabetes, or liver diseases, under anticoagulant treatment, or with coagulation abnormalities, as well as subjects for whom there was loss of medical record data, those lost to follow-up, and those submitted to low-definition laser-assisted liposuction.

The decision to perform medium- or high-definition laser-assisted liposuction relied on the patient's wishes and the author's assessment of the patient's body type (athletic or overweight, as well as an evaluation of the muscle tone), lifestyle habits (sedentary or athletic), and skin sagging (generalized or localized mainly in the upper, lower, or both abdominal regions) in the areas for treatment. The present study adopted the following concept for outcome classification to assess body contour definition: high-definition, with the creation of horizontal grooves in the subcutaneous tissue of the anterior abdominal wall, according to the individualized design of the metameres of the rectus abdominis muscle, coinciding with the tendinous muscle intersections, and some grooves in the back region, highlighting the local musculature; and medium-definition, with the absence of the horizontal and other grooves (linea semilunaris, linea alba, and “V” demarcation of the lower abdomen, iliac crest, and anterior serratus), with less definition and demarcation ([Fig. 1]).

Fig. 1 Differences in preoperative markings between medium- and high-definition procedures (author's drawings).

Out of the 342 patients treated from 2014 to 2023 with laser-assisted liposuction involving areas of the trunk (including the abdomen) and the lower and upper limbs, 134 patients were excluded from the study after the application of the exclusion criteria.

The outcomes were analyzed by the author 6 months after the surgery, in in-person assessments and through photographs, based on five criteria: degree of definition (poor – no definition; regular – mild definition; and good – more pronounced definition marks), natural appearance (yes or no), irregularities in the treated areas (yes or no), navel sagging (worse, unchanged, or improved), and patient satisfaction (yes or no).

For cases undergoing new procedures, a patient satisfaction revaluation was performed 6 months after the latest surgery. In the current study,the Fisher's exact test, the Student's t-test, and the Mann-Whitney U test were applied for the inferential assessment of the results and to establish if there was a correlation with complications.

All patients underwent an examination, and the risks and the procedure were discussed with them. After the cardiologist released the preoperative tests within normal parameters, the patients signed the preoperative informed consent form and authorized the disclosure of the surgical outcomes. The present study strictly followed all ethical guidelines of the Helsinki principle and of Resolution no. 466/12 of the Brazilian National Health Council (Conselho Nacional de Saúde, CNS, in Portuguese), which contains the guidelines and regualtions for research involving human beings.

Surgical Technique

1. Preoperative period: The markings were performed with the patient in the orthostatic position, with the abdominal muscles under flexion and contraction, to aid their definition. We made the medial and lateral markings of the rectus abdominis muscle on the linea alba and semilunar lines ([Fig. 2]).

   From July 2021 onwards, the author started to make the markings at the transverse intersections of the rectus abdominis muscle separately, using the Voluson 730 Expert ultrasound, model SP6-12, with a 6 to 12 MHz transducer, to aid in the identification of the tendinous intersections of the rectus abdominis ([Fig. 3]).

   We used the anatomy of the surface of the abdomen as a parameter to assess the preoperative anatomical limits. The upper limits were the xiphoid process and costal cartilages from the seventh to tenth ribs. The lower limits were the pubis, the pubic symphysis, and the inguinal ligaments. The upper lateral limit was the lower part of the tenth rib, and the lower limit was the iliac crest. The reference points included the navel, the linea alba (fibrous junction of the right and left rectus abdominis muscles, which descends the midline of the abdomen), the semilunar lines (lateral edges of the rectus abdominis muscles), the anterior superior iliac spine, the iliac crests, the pubic symphysis, and the inguinal folds. Thus, these parameters defined two areas for treatment on the anterior abdominal wall (abdomen and anterior flanks); one area in the thoracic wall region (pectoral muscles); three areas in the posterior region of the trunk (posterior flanks, back, and sacral); and two areas on the thighs on each side (saddlebags and inner face). The arms constituted one area on each side, and other less treated areas included the chin (one area) and the inner side of the knees, with one more area on each side ([Fig. 4]).

   In patients with poorly-defined pectoral muscles, markings were made to refine this muscle group. With the patients on their backs, the markings were performed on the flanks, back, and trapezius muscles.

2. Venous thrombosis prevention protocol: This protocol consisted of the sue of surgical compression stocking during the surgery and up to the seventh day after the procedure, as well as intermittent pneumatic compression throughout the surgery and until the patient could walk in the room. After the end of the surgery, the author prescribed low-molecular-weight heparin (enoxaparin) at a daily dose of 40 mg via the subcutaneous route for 7 days for each patient.

3. Transoperative period: The patients were under general anesthesia and artificial ventilatory support. All subjects received antimicrobial prophylaxis (cefazolin 2 g, or clindamycin 600 mg, intravenously, during anesthetic induction or up to 1 hour before). Patient positioning was as follows:

   • 3.1. First, the patient was in horizontal ventral decubitus for the treatment of the posterior region and disinfection with chlorhexidine and antisepsis with chlorhexidine alcohol. Incisions of 1 mm to 2 mm were made with a number 15 scalpel in the upper median intergluteal region, bilaterally in the median lumbar region, in the paramedian regions, and, in some cases, in the lateral region of the hips, to access the flanks. In the upper dorsal region, when required, the author made two other incisions on each side, one medial and one superolateral.

     The author performed an infiltration with lidocaine (0.05–0.1%) and epinephrine (1:1,000) at a concentration of 1:250,000 U/mL, with even distribution, using a 31-cm long Klein needle in the marked areas, respecting the maximum volume of the anesthetic agent. The volume of the tumescent solution to treat the posterior trunk region was, on average, of 2 L, with another 2 L to treat the anterior region of the trunk. After 15 to 20 minutes, the diode laser parameters were programmed and set, initially with a 915 nm wavelength for lipolysis with continuous pulses and individualized power, depending on the thickness of the fatty tissue, ranging from 12 to 16 J, based on the treatment protocols from the device manufacturer (Delight, Vydence Medical). The fiber optic energy ranged from 600 nm to 800 nm through the punctures in forward and backward movements at a speed of 10 cm every 1 to 3 seconds, per the degree of skin sagging. The author used the laser in a fan pattern in deep and superficial planes and linearly in the demarcated areas 10 to 15 times, and tried to feel the temperature with the hand flat on the treated region, performed the pinch test, and delivered up to 5,000 J every 10 cm² ([Fig. 5]).

     Next, liposuction was performed with a 3-mm curved and straight Mercedes cannula, 24.5 cm long, connected to a vacuum pump set to a vacuum pressure of 50 cm Hg. In 2020, the author started to use a skin protector fixed with a 3.0 mononylon suture on each incision to minimize skin damage at the puncture edges. The pinch test assessed the thickness of the residual subcutaneous tissue. In December 2020, the author began to use a vibrational suction device with a 4-mm cannula. After liposuction, the fiber was connected to a 980 nm diode laser to carry the energy back to the treated area and promote tissue contraction. To perform fat grafting in the buttocks, chest, or breasts, the fat was aspirated before laser application. After liposuction, only the wavelength of 980 nm was used to treat the residual fat and promote better tissue retraction. Sutures used mononylon 5.0, and occlusive dressings with Nebacetin (neomycin sulfate plus zinc bacitracin) covered the surgical incisions.

   • 3.2. Then, the patient's position was changed to horizontal dorsal decubitus, and an indwelling bladder catheterization was performed to control hydration and reduce the volume in the lower abdomen resulting from the excessive urine in the patient's bladder. After new asepsis and antisepsis and sterile field assembly, bilateral incisions were made in the pubic region, superiorly in the umbilical scar, in the upper region of the linea alba, and in the semilunar lines, when required, for the transverse treatment of the rectus abdominis, external oblique, and anterior serratus muscles.

     After the infiltration of lidocaine (0.05–0.1%) and epinephrine (1:1,000) solution at a concentration of 1:250,000 U/mL with a 31-cm Klein needle, the same procedural sequence previously described was performed according to the marking and sketching of the abdominal wall musculature in the deep and superficial tissue layers. The laser parameters were frequently reassessed according to the thickness of the fatty panniculus of the abdominal wall. For fat grafting in the subcutaneous pectoral and breast regions, the procedure began with liposuction, followed by laser application at the wavelength of 980 nm. During liposuction, to improve the visibility of the muscle design, treatment started at the superficial fat layer of the abdominal wall (Scarpa's fascia), only at the previous markings of the semilunar lines, linea alba, and tendinous intersections of the rectus abdominis muscle, as indicated, to define the intermuscular grooves. Next, by deepening the cannula, the treatment progressed to the deep layer (Camper's fascia). With this stage completed, the author proceeded to the supplementary liposuction of the deep layer, converging with the superficial layer in the main grooves of the abdominal wall, the first to undergo liposuction. If pectoral region treatment was required, two other incisions were made on the lower/lateral margin of the areolas. After liposuction and the pinch test, the author performed sutures and dressings and placed the compression garment on the patient ([Fig. 6]). The parameters for diode laser application in each region and the volume aspirated were recorded.

   Postoperative period: After 8 hours of PO care, during which the patients demonstrated the ability to eat, move, and walk without complications, they were discharged from the hospital with a prescription for analgesic agents, dipyrone, or a combination of codeine and paracetamol. The first follow-up visit occurred on the 1^st PO day to begin treatment with lymphatic drainage. Initially, lymphatic drainage was manual and, after 7 days, associated with a device combining ultrasound waves and electric currents (MANTHUS, KLD). A physical therapist specialized in dermatofunctional therapy performed 10 to 20 lymphatic drainage sessions depending on local edema and following the equipment's programming. Suture removal was performed 12 to 14 days after surgery. We allowed most patients undergoing isolated surgery to resume physical activity after 7 days. The remaining subjects were allowed to walk after 30 days and perform weight training after 3 months. We took photographs before and after surgery, including 30, 90, and 180 days, and 1 year postoperatively. The surgeon analyzed any complication through a physical examination and surface ultrasound examination to look for fibrosis and seromas.

Fig. 2 Preoperative marking for high-definition laser-assisted liposuction in a man for treatment of the abdomen, flanks, back, pectorals, and arms.

Fig. 3 Preoperative marking to identify muscle groups and tendinous intersections of the rectus abdominis muscle with complementary use of ultrasound.

Fig. 4 Identification of areas most frequently treated by laser-assisted definition liposuction (author's drawings).

Fig. 5 Right and left posterior flanks being treated with a diode laser with a 915-nm wavelength.

Fig. 6 Patient BCP, 27 years old. (A) Preoperative high-definition laser-assisted liposuction of the abdomen, flanks, and pectorals. (B) Immediate postoperative (PO) period. (C) Three months after the procedure.

Results

The current study included 241 laser-assisted definition liposuction procedures performed on 218 patients from January 2014 to December 2023, with a minimum PO follow-up of 6 months. The sample included 55 male (25.23%) and 163 female (74.77%) patients with ages ranging from 21 to 64 years. Most subjects were 40 to 49 years old (36.70%) ([Graph 1]). The BMI ranged from 18.04 kg/m² to 32.46 kg/m², with most patients being eutrophic (53.94%), followed by 41.49% of preobese patients ([Graph 2]).

Graph 1 Age group distribution of patients undergoing diode laser liposuction.

Graph 2 Distribution of patients undergoing laser-assisted liposuction according to the classification of nutritional status[27] based on the body mass index (BMI).

Procedures were performed in 1,540 body areas, with an average of 6.4 areas per patient. All patients underwent abdominal treatment (exemplified in the [Figs. 7] [8] [9]).

Fig. 7 Patient RANBPA, 36 years old. (A) Preoperative period of high-definition laser-assisted liposuction in left semi-profile, frontal, and right semi-profile positions. (B) Four months after the procedure.

Fig. 8 Patient TBZ, 31 years old, G0P0A0 (nulliparous and nulligravida). (A) Preoperative period of high-definition laser-assisted liposuction in left semi-profile, frontal, and right semi-profile positions. (B) Six months after the procedure, in the same positions.

Fig. 9 Patient DML, 39 years old, G1P1A0 (a previous pregnancy and birth). (A) Preoperative period of medium-definition laser-assisted liposuction in left semi-profile, frontal, and right semi-profile positions. (B) Six months after the procedure, in the same positions.

Out of the 241 procedures, 46.06% involved other surgeries, especially mammoplasty (42.73%) ([Table 1]).

Table 1

Associated surgeries	Frequency	Percentage
Mammoplasty	47	42.73%
Abdominoplasty	17	15.45%
Umbilical hernia	11	10.00%
Scar retouching	9	8.18%
Mini-abdominoplasty	7	6.36%
Rhinoplasty	7	6.36%
Flank dermolipectomy	4	3.64%
Blepharoplasty	3	2.73%
Facelift	3	2.73%
Gynecomastia	2	1.82%

The percentage of body fat aspirated ranged from 0.33 to 7.69% of body weight, with an average of 3.63%. In total, 7 surgeries (2.90%) exceeded the 7% weight reference for liposuction volume. However, none required packed red blood cells, and one patient presented fibrosis in the upper abdomen, in the linea alba.

The aspirated volume ranged from 300 (reoperation) to 6,000 ml, with a mean value of 2,532 mL. Among the abdominal wall procedures, 182 (75.52%) were for high definition, and 59 (24.48%) were for medium definition. There was no statistical relationship between the sec of the patient and the choice between high- or medium-definition procedures, but most men and women preferred the high-definition option. Cases of preoperative umbilical hernia underwent repair during the same operative time.

The average operative time without associated procedures was of 3 hours and 24 minutes (minimum of 40 minutes and maximum of 5 hours and 6 minutes). With associated surgeries, it was of 6 hours and 23 minutes (minimum of 2 hours and maximum of 11 hours).

[Table 2] shows the average accumulated energy in the treated body areas.

Table 2

Body areas	Minimum accumulated energy (J)	Maximum accumulated energy (J)	Mean accumulated energy (J)
Abdomen	180	24,732	3,504
Right flank	444	21,260	3,066
Left flank	350	20,156	2,965
Right dorsum	336	9,935	1,166
Left dorsum	348	8,304	1,172
Right thigh	540	13,512	725
Left thigh	528	11,128	700
Right saddlebag	224	4,256	390
Left saddlebag	300	4,144	372
Right arm	509	6,441	372
Left arm	503	6,258	370
Right pectoral region	232	5,908	153
Left pectoral region	234	4,168	131
Submental region	200	1,440	62

Among the 241 procedures, 23 (9.54%) were reoperations to treat complications or outcome adjustment (definition increase or decrease).

We recorded 17 cases of complications (7.05%), including fibrosis (5), seroma (5), a significant drop in hemoglobin (Hb) and packed cell volume (PCV) levels (3), unesthetic marks (3), and epidermolysis (1). In patients undergoing combined surgeries, we recorded four cases of seroma, one case of fibrosis, and one case of epidermolysis in the distal region of the abdomen (abdominoplasty). In subjects not undergoing combined surgeries, four had fibrosis, three had a drop in hematimetric indices requiring packed red blood cell replacement, one had seroma, and three had unesthetic marks ([Table 3]).

Table 3

Complications	Rate (%)	Relative percentage among complications	No associated surgeries: n (%)	With associated surgeries: n (%)
Seroma	2.07	29.41	1 (20)	4 (80)
Fibrosis	2.07	29.41	4 (80)	1 (20)
Unesthetic scar	1.25	17.65	3 (100)	0 (0)
Drop in hemoglobin/packed cell volume*	1.25	17.65	3 (100)	0 (0)
Epidermolysis	0.41	5.88	0 (0)	1 (100)
TOTAL	7.05	100	11 (62.5)	6 (37.5)

All patients requiring packed red blood cell transfusion or presenting fibrosis or seroma were women. Regarding unesthetic marks, 100% of the cases occurred in men. The only case of epidermolysis occurred in a male subject requiring detachment for plication of the rectus abdominis muscle, which was associated with horizontal definition in high-definition laser-assisted liposuction. There was no statistical relationship between increased incidence of complications and sex (p = 1; Fisher's exact test, with a 5% significance level). We observed seromas in the late PO period, that is, from 8 to 14 days. There was no statistical relationship between complications and higher surgical times (p = 0.7064; Student's t-test, with a 5% significance level).

Except for seroma and epidermolysis, which occurred in a higher number of patients who underwent combined surgery (four and one case, respectively), other complications, such as fibrosis, unesthetic marks, and a symptomatic drop in Hb and PCV levels, were more common among patients not submitted to associated procedures. The Fisher's exact test confirmed the relationship between combined surgeries and an increased incidence of seroma and the lack of association involving combined surgeries and an increased incidence of fibrosis, unesthetic marks, and a symptomatic drop in Hb and PCV levels (p = 0.0357, with a 5% significance level). One female patient ([Fig. 10]) presented a moderate volume of seroma at the inferior part of the left linea semilunaris on the 8th PO day after returning from a leisure trip and underwent a puncture. We repeated the puncture after 2 days, obtaining a volume of 30 mL and solving this complication. Subsequently, 1 month after surgery, lower abdomen retraction was evident. After attempts to resolve it with manipulation and shock waves, the author decided to surgically approach the region, with detachment and resection of the skin of the lower abdomen with little success, and the patient evolved with a new seroma in the lower abdomen. To solve this seroma, two punctures were performed on consecutive days. In addition, the patient presented new irregularity and skin retraction, with partial resolution with localized detachments under local anesthesia and fat grafting in the subdermis (three sessions). The dermatofunctional physical therapist solved the other cases of fibrosis using manual lymphatic drainage, ultrasound devices with electric current, vacuum cavitation devices, and even shock wave devices.

Fig. 10 Patient CVM, 51 years old, G1P1A0 (a previous pregnancy and birth). (A) Preoperative period of high-definition laser-assisted liposuction in left semi-profile, frontal, and right semi-profile positions. (B) Three months after the procedure and preoperative period of mini-abdominoplasty for the treatment of lower abdominal fibrosis in the same positions. (C) Two months after the mini-abdominoplasty and preoperative period of scar retraction detachment and fat grafting in the same positions. (D) Two months after the procedure, in the same positions.

Fibrosis consists of hardened irregularities and nodules palpable or visible in the treated areas, and surface ultrasound confirms their presence; they can also occur as retractions outside the grooves caused by the surgical technique. Unesthetic marks present as irregular grooves, often with local retraction, and are visible 18 to 30 days postoperatively.

The mean BMI among patients with complications was of 25.01 (minimum: 21.26; maximum: 30.68) kg/m². There was no statistical evidence that patients with higher BMIs presented more complications (p = 0.7033; Mann-Whitney U test, with a 5% significance level), and there was no relationship between complications and advanced patient age (p = 0.4734; Student's t-test, with a 5% significance level).

In the 5 patients with fibrosis, the average accumulated energy in the affected tissues was of 5,109.6 J (minimum: 2,832 J; maximum: 10,298 J), with all cases affecting the anterior abdominal wall. In the 3 patients with unesthetic marks, the average accumulated energy in the affected tissues was of 7,746 J (minimum: 5,234 J; maximum: 10,504 J); all cases affected the anterior abdominal wall, in the horizontal grooves created to separate the metameres of the rectus abdominis muscle. The patient who developed epidermolysis had 4,504 J of accumulated energy in the anterior abdominal region. In the 5 patients with seroma, the average accumulated energy in the affected tissues was of 2,882 J (minimum: 1,584 J; maximum, 6,490 J); 2 cases occurred in the lower abdomen, 2 cases, in the right flank, and 1 case, in the left flank. The 3 patients requiring packed red blood cells for anemia treatment underwent liposuction of, on average, 6.09% of their body weight (minimum: 5.16%; maximum: 6.97%).

The surgical correction of unesthetic marks was performed in another procedure (three other cases). The case presenting epidermolysis underwent surgical debridement, dressing application, and healing by secondary intention.

There was no statistical relationship between the number of treated areas and the complication rate (p = 0.8239; Mann-Whitney U test, with a 5% significance level) or between the percentage of body weight liposuctioned and the complication rate (p = 0.1021; Student's t-test, with a 5% significance level).

Out of the 218 patients operated on, 7 were not satisfied with the outcome (3.21%), and, of these, 3 underwent a reoperation and were satisfied after the second or third procedureS. Four patients remained dissatisfied and did not return 6 months after surgery. One was dissatisfied with the hyperchromic scars from the procedure-associated punctures. One was dissatisfied with the little improvement in the inner thigh sagging, and two were dissatisfied regarding their expectations of a more defined abdominal marking. Considering the total number of procedures performed (241), the final rate of patient dissatisfaction was of 1.67% ([Table 4]). There was no relationship involving patient satisfaction and BMI (p = 0.1456; Student's t-test, with a 5% significance level), sex (p = 0.3723; Fisher's exact test, with a 5% significance level), or age (p = 0.7924; Student's t-test, with a 5% significance level). Regarding the degree of definition, the surgeon classified 211 procedures (87.55%) as good, and 30 (12.45%), as regular, with none requiring reoperation.

Table 4

Criteria	Evaluation	n	%
Degree of definition	Poor	0	0
	Regular	30	12.45
	Good	211	87.55
Natural appearance	Yes	238	98.75
	No	3	1.24
Irregularities	Yes	11	4.56
	No	230	95.44
Navel sagging	Worse	0	0
	Unchanged	0	0
	Improved	241	100
Patient satisfaction	Yes	237	98.34
	No	4	1.66

Among the 23 reoperations, 39.13% were performed in male patients, most (44.44%) in the age group from 40 to 49 years. Women accounted for 60.87% of the reoperations, and the oldest age group ranged from 40 to 49 years (50%). A total of 17 reoperations (73.91%) were to increase the definition of the anterior abdominal wall and flanks, while 1 (4.35%) was to soften the abdominal markings. Five reoperations (21.74%) were to treat complications (fibrosis, unaesthetic marks), and all of them were performed within the first year of the first surgery ([Graph 3]). One of these 5 patients required a third surgery to complement the treatment of the unesthetic mark.

Graph 3 Distribution of indications for reoperations after laser-assisted liposuction.

Discussion

The search for safe procedures with fewer complications will always guide the development of several surgical techniques and the association of technologies to improve surgical outcomes with lower tissue damage. A diode laser at wavelengths of 915 and 980 nm facilitates liposuction due to fat emulsification, blood vessel coagulation, and collagen denaturation, promoting better skin retraction due to thermal tissue damage and neocollagenesis.[7] [8] [9] [23] [24] [25] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43]

The procedure performed in the present series consisted of creating grooves in specific locations of the abdomen, trunk, and back by removing fat accumulation in the deep and superficial layers to enable greater definition of the abdominal muscles. It is worth noting that it is not a procedure for weight loss.

The cases studied presented visible skin retraction in the treated areas and an improvement in the flaccid appearance of the navel, with a more frequent evaluation in the third month after surgery, consistent with the study by Wolfenson et al.[34]

In laser-assisted liposculpture, complications with a higher incidence, that is, above 50%, include bruising, edema, and a transient sensorial deficit in the operated region. Major complications, such as burns, nodularities, and seromas, are less frequent (below 24%).[7] [9] [25] [31] [34] [44] [45]

In the present study, the rate of fibrosis was of 2.07%, and a significant symptomatic drop in Hb and PCV levels was observed in 1.25% of the patients. In addition, an average of 3.63% of body fat was removed.

Most patients were discharged from hospital within 8 hours. Abdelaal and Aboelatta,[38] in a series of 56 patients, showed that laser lipolysis reduced the blood loss documented by the Hb levels and red blood cell counts in the liposuction device by more than 50% compared with traditional liposuction. In histological studies, other authors[7] [8] [40] [41] observed the coagulation of small blood vessels (microangiopathic coagulation) of the fatty tissue after endolaser treatment, reducing local bleeding.

The Technical Chamber of Plastic Surgery of the Brazilian Federal Council of Medicine (Conselho Federal de Medicina, CFM, Resolution no. 1,711/03) established the following safety standards: The aspirated volume should not be greater than 7% of body weight; the aspirate composition depends on the size of the cannulas, that is, the larger the cannula, the greater the tissue damage and blood loss; and the aspirated body surface should not exceed the recommended amount of 40% of the body surface.[46] [47] In the present study, the maximum aspirated volume was of 7.69%, and the maximum aspirated body surface was of 21.7%. None of the cases requiring packed red blood cell transfusion in the PO period underwent liposuction above 7% of their body weight.

Skin burns or hyperchromia in the skin of the treated areas were not observed in the current study. Some patients presented hyperchromia only in the punctures made for the passage of the cannulas and endolaser, which would occur regardless of the technique used due to the individual healing of each patient. In an article[29] on laser-assisted liposuction using Nd:YAG at a the wavelength of 1,444 nm in 64 patients, the rate of minor burns was of 3%, and this complication was attributed to the learning curve of the technique. Goldman et al.[40] reported 1 case of small-area burn among 1,734 patients treated with endolaser. During laser lipolysis, the internal temperature usually ranges from 48 to 50°C; higher temperatures can cause burns, especially in the dermis.[46] To control that, authors[31] [32] [35] [41] [43] [44] [45] suggest that the skin temperature should not exceed 42°C, since the temperature 5 mm below the subdermis is approximately 5°C higher than the superficial temperature.[31] [32] [35] [41] [43] [44] [45] Literature surveys[48] [49] have also shown that hyperchromia is a complication in conventional liposuction and technology-assisted liposuction, such as vibro-liposuction, ultrasonic liposuction, and laser-assisted liposuction.[21] [50] [51]

In the current study, there were 4 cases of seroma in patients undergoing laser-assisted liposuction and combined surgeries, and 1 case in which only laser-assisted liposuction was performed, representing 2.07% of the total complications. However, of the associated surgeries, only one case of seroma occurred in the association of laser-assisted liposuction and abdominoplasty. In the literature, the appearance of seromas was one of the complications found in the studies,[7] [39] [50] [51] [52] [53] [54] with an incidence ranging from 1.25 to 29.97%; the incidence of seroma was higher in liposuctions associated with technologies generating more heat in the tissues.

To avoid seroma, to the author avoided high accumulated energy in grooves with thin adipose panniculus and properly used compression, which is indicated to minimize the risks of this complication,[7] [50] with modelers or tapping (adhesive compression and tension dressings). Although the literature does not mention this recommendation, the author asks patients to avoid sitting for many hours throughout the day in the first 15 days after surgery, to avoid impairing adequate lymph drainage from the inguinal regions and scarring between the internal bloody tissues, forming unesthetic adhesions, as occurred in the present study when patients had to return to work early or go on long travels.

Regarding abdominoplasty, after the case of epidermolysis (0.41%) in the last flap region with good evolution, which may also have been caused by inadequate external compression, the autor decided to stop making the horizontal grooves characteristic of the high-definition procedure with abdominal flap detachment. As such, the surgeon started to perform only medium-definition procedures due to a concern with the greater devascularization of the abdominal dermal-fat flap. In 2012, Hoyos et al.[54] published a study involving 181 postpartum patients who underwent mini-abdominoplasty, plication of the rectus abdominis muscle, and definition liposculpture; they reported no skin flap necrosis but described superficial liposuction in medium-definition markings, that is, the linea alba, linea semilunaris, and oblique muscles.[54] Raghuram et al.,[55] in a meta-analysis involving 13 studies and 12,599 patients, showed that traditional liposuction with abdominoplasty presented lower flap necrosis rates than abdominoplasty alone (0.39% and 1.01%, respectively). In 2019, Viaro[52] reported 1 case (1.25%) of abdominal flap necrosis after definition liposuction and abdominoplasty. However, the risks of skin necrosis are not limited to the combination of liposuction and abdominoplasty. Other studies[9] [51] have also reported skin necrosis with liposuction alone. In 2011, Kim et al.,[51] in a study involving 2,398 cases of superficial liposuction divided into 3 subgroups (vibroliposuction, vibroliposuction with external ultrasound, and vibroliposuction with external ultrasound and endermology), reported that 4 subjects from the vibroliposuction subgroup had skin necrosis (0.6%). Another study with 534 procedures using the 980 nm diode endolaser with aspiration or local massage reported 1 case of necrosis, near the navel, which had undergone laparoscopic procedures.[9]

From an esthetic point of view, contour irregularities are the major complications significantly reducing patient satisfaction.[49] [51] In the current study, the rate of complications harming the body contour was of 5.39%. Most of these complications were feasible to correct with a single surgical procedure. Among contour irregularity-related complications, including fibrosis (nodules and retractions) and unesthetic marks (8–3.32% of the procedures, equivalent to 47% of complications), 4 underwent a second surgery to treat the complication, and 1 required a third procedure for appearance improvement. In 1994, Gasperoni and Salgarello[56] published outcomes from superficial liposuction of the abdomen, thighs, and arms, and observed a 9% complication rate, mostly contour irregularities and undulations (92%). A case review of 2,398 cases of superficial liposuction from 2010[51] divided subjects into 3 subgroups: Subgroup I consisted of 682 patients who underwent vibroliposuction, with a 12.2% complication rate; subgroup II, with 884 patients who underwent vibroliposuction with external ultrasound energy, had a 2.2% complication rate; and subgroup III, with 832 patients who underwent vibroliposuction with external ultrasound energy and endermology, had a 7.6% complication rate. Among the patients with contour irregularities (71; 8.45%), additional surgeries or fat grafting (40 reoperations; 1.66%) solved virtually most cases, except for 6 patients who remained dissatisfied. A total of 21 patients (52.5%) underwent a third procedure but were still dissatisfied. In the current study, all subjects undergoing a second or third surgery were satisfied. Another study by Sazaki and Tevez[41] reported nodules in 5% of patients within 6 weeks, especially in the upper abdomen and periumbilical region, treated with external ultrasound. Other authors[6] [50] [57] [58] also described nodules treated with combined technologies and liposuction.

The greater the difference in volume between the less aspirated areas and the more aspirated sulcus regions, the greater the definition and the chances of artificial results and possible anatomical distortions caused by future variations in body weight. As such, the author tries to maintain a pinch test ratio of 1:2 between grooved and liposuctioned areas. In some studies, the reference for completing endolaser application is measuring the skin temperature with an external thermometer and stopping the procedure when reaching 34 to 42°C.[7] [30] [31] [32] [36] [38] [41] [43] [46] [58] However, in the present study, the author opted for tactile temperature control,[7] [8] [9] [10] by palpating the area under treatment, performing the pinch test,[7] [33] [35] and observing the accumulated energy recorded by the laser device.[8] [29] [32] [33] [34] [57] The pinch test is an important maneuver for any experienced liposuction surgeon and should be used preoperatively to assess skin thickness and fat thickness; intraoperatively, to monitor the progress of the procedure; and postoperatively, to evaluate the quality of the outcome.[35]

Female patients, the most prevalent in the current study, present cellulitis or gynoid lipodystrophy due to the anatomical characteristics of the superficial areolar tissue. In male subjects, the fibrous septa are smaller and arranged in oblique planes with small fat lobules; in women, the lobules are larger and present parallel septa. In the subcutaneous tissue, the percentage of superficial adipose tissue compared with that of deep adipose tissue is of approximately 49% in women and 34% in men, implying differences in body contour and location of fat accumulation.[17] Outcome assessment must consider other aspects besides sex and age, such as body areas (abdomen, flanks, and trunk) and the fibrous septa connected to the muscle fascia. The greater the sagging on the region for treatment, the greater the difficulty in providing a more satisfactory outcome with just one laser application; better outcomes require more frequent laser applications. In 2019, Danilla et al.[50] reported that the 33 patients (7.91%) in who had poor definitions or unnatural results were overweight or presented sagging. We only requested postoperative imaging tests for patients undergoing a second or third procedure.

The effects of laser-assisted lipolysis result from thermal energy. Laser light undergoes conversion into thermal energy in fat, collagenous tissues (due to their water content), and hemoglobin.[45] Different wavelengths have different absorption coefficients for fat, water, and hemoglobin; the water content ranges from 14% to 17% in fat, and from 60 to 70% in collagen.[7] [45] The duration of laser activity in tissues is highly variable and depends on the total treatment area, the thickness and volume of fat for removal, the degree of skin laxity, and the presence of previous internal scars (such as those from a secondary procedure).[35]

Water absorbs the wavelengths of 1,064 and 980 nm wavelengths better than fat.[7] [32] [59] The 1,064 nm ND:YAG laser does not have a high affinity for fat; however, fat cells absorb better 924 nm wavelength laser.[45] From 900 to 950 nm, absorption by fat is higher than by water. The absorption coefficient for fat at 924 nm is 7 times higher than at 1,064 nm.[32] At 975 nm, the peak absorption by water is greater than at 1,064 nm.[32] [59] Anderson et al.[59] observed that the wavelengths of 915 nm, 1,210 nm, and 1,720 nm are more selective for fat than water ([Fig. 11]). The 1,444-nm wavelength has much more affinity for water than fat.[7]

Fig. 11 Water and human adipose tissue absorption coefficients and light wavelengths.

In the current survey, the average accumulated energy in the abdomen was of 3,504 J, of 3,066 J in the right flank, and of 2,965 J in the left flank. Studies[8] [9] [23] have shown that the application of 980 nm and 1064 nm, that is, low-energy laser, causes reversible adipocyte damage, consistent with the swelling of this cell type; higher energies rupture adipocytes and coagulate collagen fibers and small vessels, making the damage irreversible. Another study[33] obtained good outcomes by treating the abdomen with an accumulated energy of 2,000 J. Badin et al.[39] showed that, in a patient treated with laser-assisted liposuction using 1,064-nm Nd:YAG, the area treated with 3,000 J of accumulated energy presented irreversible damage (cytoplasmic retraction and membrane lysis).

In contact with fatty tissue, the light energy from the laser undergoes absorption and conversion into heat, expanding the content of the adipocytes and breaking their cell membranes.[8] The energy produced at the fiber tip can accumulate at levels harmful to the tissue. Excessive subcutaneous or cutaneous thermal lesions may occur, leading to tissue carbonization.[23] [35] Due to this concern, in more fibrous tissues, the procedure used lower energies and less accumulated energy not to increase the risk of tissue overheating and, consequently, produce more irregularities.

The laser application speed was ≤ 10 cm/s, and varied according to the need for greater laser action in the operated region (in cases of greater thickness of the area to be treated, in the hypodermis and dermis, for example), which is consistent with the literature.[31] [35] [57] [58]

In the present study, in the cases treated with the 915-nm wavelength, the lipoaspirate was less bloody than when this wavelength was not used; however, for cases requiring fat grafting, the use of this wavelength was lower, as suggested by other studies.[35] [37] The 980 nm wavelength was effective for visibly-noticeable skin retraction, consistent with the literature.[7] [9] [26] [31] [32] [33] [34] [58] [60] The result improved every month, especially after the third month, and it became even more perceptible in cases in which a new procedure was performed, with long-lasting outcomes. Although the study group involved procedures with a minimum PO follow-up period of 6 months, except for 4 dissatisfied patients who did not want to return after this time, all remaining subjects underwent follow-up for up to 1 year postoperatively and some, for longer, as they were regular patients who underwent other procedures years later, which enabled monitoring of the results and their durability.

Due to the complications presented by the patients of the present study, mainly unesthetic marks and fibrosis, the author lowered the energy accumulated in the areas for treatment, in subsequent cases, which is consistent with the learning curve of the technique and technology. Surgeons must consider the skin type, panniculus thickness, and patient profile when deciding on the energy power for application and the energy accumulated in the tissues to be treated, always seeking the best for each case.

The main indication for laser lipolysis and laser-assisted liposuction is body contouring as a primary or secondary procedure. This technique can be useful in small, well-defined, localized fat accumulations or large areas for body contour. The number of surgical candidates is higher than in conventional liposuction, as laser-assisted liposuction can treat selected subjects with skin laxity who would not have an acceptable skin adaptation with the traditional techniques.[35]

Using a diode laser at a wavelength of 980 nm during liposuction has been established as an effective and safe alternative to conventional liposuction, with satisfactory objective and subjective outcomes and a low complication rate.[7] [9] [26] [31] [32] [33] [34] [58] [60] However, the limitations of the current study include the retrospective and non-comparative analysis of laser-assisted definition liposuction and difficulties in standardizing methods for outcome assessment. The literature contains a single case study[48] using endolaser in high-definition liposuction other than the one already published by the author of the present study.[26] However, in that study,[48] two different surgeons performed the procedures, 1 using VASER (ultrasonic liposuction) and the other using laser-assisted liposuction at 980 nm, but the results were not separated, but combined into a single group, without distinction, hindering specific data comparison with the data of the present study on the use of endolaser in definition liposuction. Further studies are required to optimize the efficacy and safety of the treatment and, above all, standardize outcome evaluation.

Conclusion

Laser-assisted liposuction for definition, using the wavelengths of 915 and 980 nm, was a feasible and reproducible technique to improve body contour and muscle definition in this study sample. Laser-assisted liposuction for definition presented satisfactory outcomes in more than 98% of the cases, with a low complication rate.

Conflito de Interesses

O autor não tem conflito de interesses a declarar.

Author's Contributions

RPM: data analysis and/or interpretation, final manuscript approval, funding acquisition, data collection, conceptualization, study conception and design, resource management, project management, investigation, methodology, performance of surgeries and/or experiments, writing – original draft, writing –review & editing, supervision, validation, and visualization.

• Referências

• 1 Schrudde J. Lipektomie und Lipexhaerese im Bereich der unteren Extremitäten. Langenbecks Arch Chir 1977; 345: 127-131
• 2 Schrudde J. Lipexeresis as a means of eliminating local adiposity. Aesthetic Plast Surg 1980; 4 (01) 215-226
• 3 Illouz YG. Surgical remodeling of the silhouette by aspiration lipolysis or selective lipectomy. Aesthetic Plast Surg 1985; 9 (01) 7-21
• 4 Hakme F, Toledo OMR, Souto AM, Moojen JGN, Sjostedt CO. Detalhes técnicos na lipoaspiraçäo associada à abdominoplastia. Rev Bras Cir 1985; 75 (05) 331-337 . Available from https://pesquisa.bvsalud.org/portal/resource/pt/lil-31375 . cited 2024 Jun 16 [Internet]
• 5 Pinto EBdS, Erazo I PJ, Prado Filho FSA, Muniz AC, Salazar GH. Superficial liposuction. Aesthetic Plast Surg 1996; 20 (02) 111-122
• 6 Saldanha OR, Pinto EB, Matos Jr WN, Lucon RL, Magalhães F, Bello EM. Lipoabdominoplasty without undermining. Aesthet Surg J 2001; 21 (06) 518-526
• 7 Dornelles RdFV, Silva AdLe, Missel J, Centurión P. Laserlipólise com diodo 980 nm: experiência com 400 casos. Rev Bras Cir Plást 2013; 28 (01) 124-129
• 8 Goldman A. Submental Nd:Yag laser-assisted liposuction. Lasers Surg Med 2006; 38 (03) 181-184
• 9 Reynaud JP, Skibinski M, Wassmer B, Rochon P, Mordon S. Lipolysis using a 980-nm diode laser: a retrospective analysis of 534 procedures. Aesthetic Plast Surg 2009; 33 (01) 28-36
• 10 Pereira-Netto D, Montano-Pedroso JC, Aidar ALES, Marson WL, Ferreira LM. Laser-Assisted Liposuction (LAL) Versus Traditional Liposuction: Systematic Review. Aesthetic Plast Surg 2018; 42 (02) 376-383
• 11 Hunstad JP. Tumescent and syringe liposculpture: a logical partnership. Aesthetic Plast Surg 1995; 19 (04) 321-333
• 12 Fernandes JW, Miró A, Rocha AAdA, Mendonça CT, Franck CL, Itikawa WM. Practical criteria for a safer liposuction: a multidisciplinary approach. Revista Brasileira de Cirurgia Plástica 2017; 32 (03) 454-466
• 13 Mentz III HA, Gilliland MD, Patronella CK. Abdominal etching: differential liposuction to detail abdominal musculature. Aesthetic Plast Surg 1993; 17 (04) 287-290
• 14 Lancerotto L, Stecco C, Macchi V, Porzionato A, Stecco A, De Caro R. Layers of the abdominal wall: anatomical investigation of subcutaneous tissue and superficial fascia. Surg Radiol Anat 2011; 33 (10) 835-842
• 15 Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg 1991; 87 (06) 1009-1018
• 16 Gasperoni C, Salgarello M. Rationale of subdermal superficial liposuction related to the anatomy of subcutaneous fat and the superficial fascial system. Aesthetic Plast Surg 1995; 19 (01) 13-20
• 17 Cunha MGd, Cunha ALGd, Machado CA. Hipoderme e tecido adiposo subcutâneo: duas estruturas diferentes. Surg Cosmet Dermatol 2014; 6 (04) 355-359 . Available from http://www.surgicalcosmetic.org.br/Content/imagebank/pdf/v6/6_n4_361_en.pdf [Internet]
• 18 Illouz YG. Surgical implications of “fixed points”: a new concept in plastic surgery. Aesthetic Plast Surg 1989; 13 (03) 137-144
• 19 Ersek RA, Salisbury AV. Abdominal etching. Aesthetic Plast Surg 1997; 21 (05) 328-331
• 20 Cipriani RM. Lipomarcación de Alta Definición: reporte de dos casos. Horiz Med 2015; 15 (02) 70-75 . Available from: http://www.scielo.org.pe/scielo.php?script=sci_abstract&pid=S1727-558X2015000200011&lng=pt&nrm=iso&tlng=es
• 21 Hoyos AE, Millard JA. VASER-assisted high-definition liposculpture. Aesthet Surg J 2007; 27 (06) 594-604
• 22 Apfelberg DB, Rosenthal S, Hunstad JP, Achauer B, Fodor PB. Progress report on multicenter study of laser-assisted liposuction. Aesthetic Plast Surg 1994; 18 (03) 259-264
• 23 Mordon S, Eymard-Maurin AF, Wassmer B, Ringot J. Histologic evaluation of laser lipolysis: pulsed 1064-nm Nd:YAG laser versus cw 980-nm diode laser. Aesthet Surg J 2007; 27 (03) 263-268
• 24 Tagliolatto S, Medeiros VB, Leite OG. Laserlipólise: atualização e revisão da literatura. Surg Cosmet Dermatol (Impr) 2012; 4 (02) 164-174 . Available from: http://www.surgicalcosmetic.org.br/Content/imagebank/pdf/v4/4_n2_203_pt.pdf
• 25 Katz B, McBean J, Cheung JS. The new laser liposuction for men. Dermatol Ther 2007; 20 (06) 448-451
• 26 Motta RP. Lipoaspiração laser-assistida de alta definição. Revista Brasileira de Cirurgia Plástica 2018; 33 (01) 48-55
• 27 WHO Consultation on Obesity. (1999: Geneva S, Organization WH. Obesity: preventing and managing the global epidemic: report of a WHO consultation [Internet]. iris.who.int World Health Organization; 2000. . Available from: https://iris.who.int/handle/10665/42330
• 28 Bukret WE, Alonso GF. Use of 3D geometrical models to improve efficacy and safety of Laser-assisted liposuction: a prospective study. Revista Bras Cir Plást 2015; 30 (03) 381-390
• 29 Jomah J. High definition body contouring using Laser Assisted Liposculpture (LAL) the 1444 N D. EJAMED 2013;3(1):
• 30 Goldman A, Wollina U, Mundstock ECd. Evaluation of tissue tightening by the subdermal Nd: Yag laser-assisted liposuction versus liposuction alone. J Cutan Aesthet Surg 2011; 4 (02) 122-128
• 31 Mordon SR, Wassmer B, Reynaud JP, Zemmouri J. Mathematical modeling of laser lipolysis. Biomed Eng Online 2008; 7: 10
• 32 Moreno-Moraga J, Torre JRdL. Our Experience Treating 500 Lipodystrophic Areas with a 924/975 nm Laser, a New Device That Induces Lipolysis and Heating of the Dermis and Fibrous Septa of Fatty Tissue. Journal of Clinical Dermatology 2010;1(2)
• 33 Senra AB. Avaliação de 10 anos de laserlipólise em 766 pacientes. Rev Bras Cir Plást 2013; 28 (03) 389-397 . Available from https://www.rbcp.org.br/Content/imagebank/pdf/v28n3a11.pdf . cited 2024 Jun 16 [Internet]
• 34 Wolfenson M, Roncatti C, Alencar AHd, Barros T, Silva Neto JFd, Santos Filho Nd. Laserlipólise: redução da pele e prevenção de umbigo flácido nas lipoplastias seguindo parâmetros de segurança no uso do laser de diodo - com duplo comprimento de onda 924 e 975 nm. Rev Bras Cir Plást 2011; 26 (02) 259-265 . Available from https://www.rbcp.org.br/Content/imagebank/pdf/v26n2a12.pdf . cited 2024 Jun 16 [Internet]
• 35 Goldman A, Gotkin RH. Laser-assisted liposuction. Clin Plast Surg 2009; 36 (02) 241-253 , vii, discussion 255–260
• 36 Salzman MJ. Laser lipolysis using a 1064/1319-nm blended wavelength laser and internal temperature monitoring. Semin Cutan Med Surg 2009; 28 (04) 220-225
• 37 Jecan CR, Hernic AD, Tianu EC, Florescu IP, Lascăr I. Histological differences between laser-assisted and suction-assisted lipoplasty aspirates - a comparative study. Rom J Morphol Embryol 2015; 56 (2 Suppl): 797-801
• 38 Abdelaal MM, Aboelatta YA. Comparison of Blood Loss in Laser Lipolysis vs Traditional Liposuction. Aesthet Surg J 2014; 34 (06) 907-912
• 39 Badin AZED, Gondek LBE, Garcia MJ, Valle LC, Flizikowski FBZ, Noronha Ld. Analysis of laser lipolysis effects on human tissue samples obtained from liposuction. Aesthetic Plast Surg 2005; 29 (04) 281-286
• 40 Goldman A, Schavelzon D, Blugerman G. Laserlipólise: Lipoaspiração com Nd-YAG Laser. Rev Bras Cir Plást 2002; 17 (01) 17-26 . Available from http://www.rbcp.org.br/details/257/pt-BR/laserlipolise–lipoaspiracao-com-nd-yag-laser cited 2024 Jun 16 [Internet]
• 41 Sasaki GH, Tevez A. Laser-assisted liposuction for facial and body contouring and tissue tightening: a 2-year experience with 75 consecutive patients. Semin Cutan Med Surg 2009; 28 (04) 226-235
• 42 Khoury JG, Saluja R, Keel D, Detwiler S, Goldman MP. Histologic evaluation of interstitial lipolysis comparing a 1064, 1320 and 2100 nm laser in an ex vivo model. Lasers Surg Med 2008; 40 (06) 402-406
• 43 DiBernardo BE, Reyes J. Evaluation of skin tightening after laser-assisted liposuction. Aesthet Surg J 2009; 29 (05) 400-407
• 44 Ali YH. Laser-assisted Lipolysis Burn Safety: Proposed Detailed Parameters with Assessment of Their Efficacy and Safety. Plast Reconstr Surg Glob Open 2018; 6 (10) e1934
• 45 Parlette EC, Kaminer ME. Laser-assisted liposuction: here's the skinny. Semin Cutan Med Surg 2008; 27 (04) 259-263
• 46 Conselho Federal de Medicina. Resolução CFM n° 1.711/2003. Brasília, DF: Diário Oficial da União; 2004. . Available from: https://sistemas.cfm.org.br/normas/visualizar/resolucoes/BR/2003/1711
• 47 Matos Júnior WN, Jiménez FVC, Rocha RPd, Ribeiro SM, Ribeiro RC. Estudo Quantitativo da Superfície Corpórea de Interesse para a Lipoaspiração. Rev Bras Cir Plást 2001; 20 (01) 22-25 . Available from http://www.rbcp.org.br/details/149/pt-BR/estudo-quantitativo-da-superficie-corporea-de-interesse-para-a-lipoaspiracao cited 2024 Jun 16 [Internet]
• 48 Dixit VV, Wagh MS. Unfavourable outcomes of liposuction and their management. Indian J Plast Surg 2013; 46 (02) 377-392
• 49 Wu S, Coombs DM, Gurunian R. Liposuction: Concepts, safety, and techniques in body-contouring surgery. Cleve Clin J Med 2020; 87 (06) 367-375
• 50 Danilla S, Babaitis RA, Jara RP, Quispe DA, Andrades PR, Erazo CA. et al. High-Definition Liposculpture: What are the Complications and How to Manage Them?. Aesthetic Plast Surg 2020; 44 (02) 411-418
• 51 Kim YH, Cha SM, Naidu S, Hwang WJ. Analysis of postoperative complications for superficial liposuction: a review of 2398 cases. Plast Reconstr Surg 2011; 127 (02) 863-871
• 52 Viaro MSS. Lipoaspiração de definição abdominal. Rev Bras Cir Plást 2019; 34 (03) 336-343 . Available from https://www.rbcp.org.br/details/2645/pt-BR/lipoaspiracao-de-definicao-abdominal [Internet]
• 53 Saad AN, Pablo Arbelaez J, De Benito J. High Definition Liposculpture in Male Patients Using Reciprocating Power-Assisted Liposuction Technology: Techniques and Results in a Prospective Study. Aesthet Surg J 2020; 40 (03) 299-307
• 54 Hoyos AE, Perez ME, Castillo L. Dynamic definition mini-lipoabdominoplasty combining multilayer liposculpture, fat grafting, and muscular plication. Aesthet Surg J 2013; 33 (04) 545-560
• 55 Raghuram AC, Yu RP, Gould DJ. The Addition of Partial or Circumferential Liposuction to Abdominoplasty Is Not Associated With a Higher Risk of Skin Necrosis. Aesthet Surg J 2021; 41 (06) NP433-NP444
• 56 Gasperoni C, Salgarello M. MALL liposuction: the natural evolution of subdermal superficial liposuction. Aesthetic Plast Surg 1994; 18 (03) 253-257
• 57 Tagliolatto B, Medeiros B, De V. et al. Surg Cosmet Dermatol 2011
• 58 Palm MD, Goldman MP. Laser lipolysis: current practices. Semin Cutan Med Surg 2009; 28 (04) 212-219
• 59 Anderson RR, Farinelli W, Laubach H, Manstein D, Yaroslavsky AN, Gubeli III J. et al. Selective photothermolysis of lipid-rich tissues: a free electron laser study. Lasers Surg Med 2006; 38 (10) 913-919
• 60 Wassmer B, Zemmouri J, Rochon P, Mordon S. Comparative study of wavelengths for laser lipolysis. Photomed Laser Surg 2010; 28 (02) 185-188

Publication History

Received: 22 November 2024

Accepted: 06 February 2025

Article published online:
14 May 2025