Body Shaping

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Body Shaping Overview

Given the growth in medical weight management, as evidenced by the unprecedented demand for the International Association for Physicians in Aesthetic Medicine’s (IAPAM’sNEW full-day hCG/Physician Weight Loss Training, the concomitant market for body shaping will grow significantly in 2010. From innovative new uses for ultrasound in lipolysis, to the use of cryolipolysis, and the growing use of laser-assisted lipolysis, patients now have a number of non-surgical options for body sculpting.

Experts agree that there “are a slew of cutting-edge devises on the horizon, all with the ability to bring changes to body and skin completely non-invasively.” From Zeltiq to Zerona, these and other devices will be made widely available this year and represent a clear indication of where aesthetics is heading. The two things patients are most concerned with are minimal downtime and getting great results.

Jeff Russell, Executive Director of the IAPAM, offers this forecast, particularly regarding fat reduction. “Syneron Velashape, as well as the potential new competitors: Ultrashape and Liposonix, will provide new options for those who have localized fat deposits and are looking for minor re-shaping of their body.” However, Jeff adds, that for more “effective contouring, the laser-assisted lipolysis machines like the Cynosure SmartLipo, and Palomar SlimLipo and the ultrasound based Vaser, offer the best results.”

“We would all like a “zero-invasive” way to re-shape the body, but the results just aren’t there yet with these completely non-invasive options (i.e. Zerona, Ultrashape, VelaShape),”concludes Russell.

Ultimately, all physicians agree that technological advancements in fat removal equipment “will allow this treatment to regain its popularity.” The following new and established remarkably non-invasive options will re-position body trimming as one of the more popular aesthetic medicine treatments.

Cryolipolysis

Cryolipolysis is the latest in a series of innovations from the Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School. The initial Cryolipolysis research and patents were originated at The Wellman Center by Dr. Dieter Manstein and Dr. R. Rox Anderson. The first scientific publication about Cryolipolysis was presented by Dr. Manstein at the 2008 meeting of the American Society for Laser Medicine and Surgery (ASLMS).

Cryolipolysis is a non-invasive treatment that uses cold temperatures to reduce fat tissue on areas of the body with the densest amount of fat tissue, such as the abdomen, back, waist and thighs. Cryolipolysis goes against the conventional treatment of fat tissue from the last 20 years in that instead of using heat to “melt” fat, cold temperatures are used to “freeze” fat. In the past, the epidermis was cooled to prevent blistering while the dermal layers were heated. With Cryolipolysis, the cold can breakdown areas of fat tissue by targeting adipocytes (fat cells) – once the adipocytes have shrunk or withered from the cold temps, they will eventually be metabolized by the lymphatic system.

Cryolipolysis is performed in a doctor’s office and involves placing a flat, saucer-shaped, suction-cup device (approximately 3-4cm wide) on the area of treatment. The device cools rapidly and is held on the area between 5-20 minutes. This method affects, or “freezes”, the subcutaneous layers of fat tissue without disturbing the normal temperature of the epidermis. In animal studies, fat breakdown has been shown to occur at –1 degree Celsius (approximately 31 degrees Fahrenheit). Since treatment areas need to reach cold enough temps in increments, one session can last up to one hour, with additional sessions needed on a case-by-case basis.

Source:  http://www.carefair.com/Body/What_is_Cryolipolysis_8234.html

Zeltiq

The ZELTIQ system utilizes a patented method called Cryolipolysis™ (the use of precisely controlled cooling to remove fat) that is designed to only kill fat cells and not cause the injury to the skin or other tissue that results from liposuction. This non surgical alternative to liposuction may meet the needs of patients who are unwilling or hesitant to undergo surgery for fat removal.

ZELTIQ has exclusive rights to this innovative new approach to removing fat.

For more information on Cryolipolysis and Zeltiq, see http://www.zeltiq.com/en-uk/for-physicians/cryolipolysis.cfm

Laser-Assisted Lipolysis and Liposuction

Laser-assisted lipolysis and liposuction, utilized in Europe for over a decade, was first introduced in the US in 2007.  Laser-assisted lipolysis is one of the newest liposuction techniques. Similar to other techniques of liposuction, laser-assisted liposuction requires the use of tumescent solution prior to lipolysis, and standard liposuction to aspirate the liquefied fat.

The laser energy is delivered by a thin laser fiber that is inserted through small incisions in the skin. In addition to breaking up fat cells, the laser energy also heats other tissues. Possible side effects include, but are not limited to, swelling, bruising, burns, numbness and minimal bleeding.

The laser is deemed a safe and effective device by the FDA. The only study that has scientifically compared this to standard liposuction has found no differences between these techniques in terms of the results. The best procedure for a patient depends on many factors which is why a thorough consultation with a plastic surgeon is beneficial.

Source:  ASPS Technology Briefs, http://www.plasticsurgery.org/Media/Technology_Briefs

SmartLipo

Cynasure’s Smartlipo laser-assisted lipolysis system is a highly efficacious solution for destroying and permanently eliminating fat cell.

The procedure disrupts the fat cells through a thermal and photodisruptive action – heating and shattering the fat cell membrane. The laser coagulates the underlying vessels due to the hemostatic properties of the laser, resulting in less bleeding, bruising, trauma as well as less down time. As an added benefit, the system has also been reported to promote tissue tightening through bulk thermal heating and tissue coagulation.

The procedure is commonly performed under local and tumescent anesthesia. A laser fiber is introduced through a hand-piece and detachable cannula. The cannula is then inserted through a 1 to 2 mm incision in the skin and into fat pockets. The cannula, with the tip of the fiber exposed approximately 2 mm, is then moved in a “back and forth” fanning motion. The laser’s aiming beam can be visualized through the skin, allowing the physician to identify the treatment area. As the fiber tip comes in contact with the fat cells it ruptures the cell membranes and releases the fatty oil from the fat cells. This end product may then be aspirated from the site.

•Smartlipo can supplement or augment traditional methods of cellulite treatment.

•A confluent red diode laser provides a powerful visual guide during treatment.

•Typically only one short treatment session is needed—enabling you to maximize your client throughput.

For more information on Cynasure’s SmartLipo systems, see http://www.cynosure.com/products/index.php

SlimLipo

Palomar’s SlimLipo was the first laser to be approved by the FDA to be used for fat dissolution.

According to FDA documents, the SmartLipo laser is intended for the surgical incision, excision, vaporization, ablation, and coagulation of soft tissue. While all soft tissue is included, it is also indicated for laser-assisted lipolysis.

This laser technology produces a burst of energy as it enters the fatty tissue that liquefies the fat.

Source:  ASPS Technology Briefs, http://www.plasticsurgery.org/Media/Technology_Briefs/Laser-assisted_liposuction_(SmartLipo).html

Zerona

The Zerona is a high fluence, low level laser therapy involving an array of diode laser devices positioned above the body of the patient, there is no pain, no downtime and no recovery. The patient lies for 20 minutes on their front side and 20 minutes on their back side. The 635 array of diode lasers emit up to 15 miliwatts at each source and focus the painless energy on the fat between the neck and the mid thighs. The characteristics of this diode laser light are such that over a series of treatments, performed every 48hrs, an opening is created in the cell membrane of the fat cells and the in Trigylceride contents of the fat cells are released into the space between the cells where they triglyceride are eliminated safely and effectively by the bodies normal carry protein systems.

The Zerona Laser Slimming program generally involves a 1 month commitment on the part of the patient, 1 week after the consultation is spent preparing incremental space and body with some diet modifications, walking, fluid intake and some homeopathic supplements. Then there are the 6 Zerona treatments performed every 2nd day over two weeks, each treatment lasting 40 minutes followed by a one week post treatment period. After one month there is a circumferential measurement test and pinch test, all comparing to the pre-treatment status. In my study, like other published series, there was a greater than 90% successful response rate of patients with the Zerona treatment. Response is defined as between a 3-9 inches measurable reduction and multiple body treatment areas.

Source:   R. Stephen Mulholland, MD for RealSelf

AccuSculpt/AccuLiftTM Laser Lipolysis System

Laser assisted liposuction is one of the many tools plastic surgeons are finding useful as demand continues for less invasive body shaping procedures. A newcomer to the market, recently receiving regulatory clearance from the FDA, the AccuSculptTM Laser Lipolysis System, according to the manufacturer, is the first Pulsed Nd:YAG Laser to deliver a 1444 nanometer(nm) wavelength. The special wavelength is said to allow for improved accuracy, precision, control and minimally-invasive deep tissue heating. For areas of the face, the AccuLift facial contouring procedure applies the AccuSculpt system with a very small cannula.

According to the manufacturer, AccuSculpt laser-lipolysis is indicated for the surgical incision, excision, vaporization, ablation, and coagulation of soft tissue. The unique wavelength provides significantly more absorption than other wavelengths. This is said to translate into much quicker fat emulsification with very low peripheral thermal damage.

Post-operative pain and swelling can occur, and burns may be possible. AccuSculpt is used on all areas of the body. The target age for patients is 20 to 70. Generally, younger, more elastic skin has greater ability to tighten or contract after subsurface volume reduction, otherwise older, less elastic skin is less able to adjust.

Source:  ASPS Technology Briefs,http://www.plasticsurgery.org/Media/Technology_Briefs/AccuSculptAccuLift™_Laser_Lipolysis_System.html

Ultrasound Assisted Lipolysis and Liposuction

Ultrasound assisted liposuction (UAL) and/or lipolysis can be both internal and external.

External ultrasound-assisted liposuction is a technique that requires trans-cutaneous application of high-frequency ultrasonic fields delivered into ‘wetted’ tissue, followed by traditional aspirative liposuction, with the goal of improving the mechanical removal of adipose cells.

Internal ultrasound-assisted liposuction uses hollow cannulas for simultaneous aspiration and ultrasound delivery, allowing the quality of the aspirate to be monitored.

Most plastic surgeons with experience with UAL have reported better results with less fatigue in treating fibrous areas, such as the back, upper abdomen, and posterior hip rolls. Areas with less dense fat such as the inner knee and medial thigh generally do not benefit from application of ultrasound with lipoplasty. (UAL is an adjunct to lipoplasty rather than an alternative methodology.)

Second-generation devices (eg, Lysonix, Mentor) use hollow cannulas for simultaneous aspiration and ultrasound delivery, allowing the quality of the aspirate to be monitored. When the aspirate changes from pale yellow to pink or gray, emulsification is complete.

Second-generation devices have certain disadvantages, as well. They are relatively large in diameter (≥5 mm), which requires longer incisions in order to accommodate skin protectors. The lumen is small, resulting in inefficient aspiration; therefore, a 2-stage procedure is generally performed with a second aspiration-only component. Additionally, the ultrasound energy is focused in a longitudinal direction, directly away from the tip; this may increase the risk of burns.

Third-generation technology returns to the solid probe with some changes in probe design -VASER. Grooves in the probe near the tip result in radial dispersion of acoustic energy, yielding more effective emulsification with lower total energy application. These probes are 2.9 mm and 3.7 mm in diameter, so smaller incisions are required.

Some discussion remains as to whether UAL enhances skin retraction. Since this is a difficult phenomenon to measure objectively, claims that indications for the use of UAL extend to large-volume cases or to patients with lax skin have not been supported. Presumably, skin retraction would be stimulated by controlled thermal injury to dermal collagen. Current techniques and technology are not developed to the state that this can be accomplished safely and predictably.

The use of UAL for very large volume fat removal is also controversial. Since a wet environment is necessary for effective conduction of acoustic energy into adipose tissue, infusion of a wetting solution is required. The ratio of wetting solution infused to anticipated fat aspiration is 1:1.5-2, regardless of whether this results in tissue tumescence. Although it may be possible to accomplish massive fat aspiration with minimal blood loss, the requisite amounts of wetting solution are associated with substantial fluid shifts postoperatively.

The American Society of Plastic Surgeons (ASPS) recommends that outpatient lipoplasty be limited to 5000 mL of total aspirate, regardless of the technique.

Sources:  “Liposuction, Internal Ultrasound-Assisted,” by Richard A. Baxter, MD, 2008 and “Liposuction, External Ultrasound-Assisted,” by Christian N. Kirman MD et al., 2009.

Ultrasound based Vaser

VASER is a fat pre-treatment device based on the emission of pulsed or continuous ultrasound energy to emulsify fat before its aspiration by means of suction-assisted lipoplasty or power-assisted lipoplasty. If compared with previous generation UAL machines, it carries important technological advances that focus on the safety and efficiency of the process. VASER is the result of improvements in surgical instrumentation and technique, proper use of wetting solutions, and knowledge about the best use of ultrasound for fat fragmentation. With its thinner cannulas and decreased use of ultrasonic energy, it allows greater emulsification of fat, creates more tunnels, diminishes the operative time, preserves vessels and nerves, and causes less pain and hematomas.

Source: E. B. de Souzo Pinto, “Liposuction and VASER,”  Clinics in Plastic Surgery, Volume 33, Issue 1, Pages 107-115 (January 2006).

Tumescent liposuction involves the injection of a fluid into the fatty tissue layer that causes blood vessels to shrink and the fat to expand, making it easier to remove and lowering the risk of a complication.  VASER lipo involves an additional step, in which the fat (after injection of fluid but before suction is applied) is treated with ultrasound energy. Unlike the laser filaments used in the other devices mentioned above, the VASER probe is blunt and the ultrasound energy it uses is much more specific for fat, so that the risk of injury to the blood vessels and nerves, as well as the muscles and skin are much lower. This is seen in the patient experience of reduced swelling and bruising.

Source:   Armando Soto, MD, Orlando Plastic Surgeon for RealSelf.com

Non-invasive trans-dermal focused ultrasound

The following systems, Liposonix and UltraShape, are completely “non-invasive,” and utilize the body’s endogenous processes to clear the fat.

Fat Cell Clearance using Non-thermal, Focused Ultrasound for Non-invasive Selective fat Cell Disruption (lysis)

After disruption of adipose tissue, the released fat and cellular debris are cleared by endogenous processes. Adipocytes consist predominantly of a triglyceride-rich lipid globule, which comprises 80-90% of the adipocyte volume. The nucleus and scant cytoplasm are squeezed to one side of the cell. Cholesterol comprises only 2-3% of the adipocyte content. The remainder of the content is primarily water, with small amounts of protein and nucleic acids.

The triglycerides released after treatment are slowly absorbed. Via a combination of metabolic events and trafficking into the systemic circulation, they re-enter the total body pool of lipids. Each triglyceride molecule is enzymatically metabolized by endogenous lipases to glycerol and three molecules of free fatty acid. The glycerol, which is water-soluble, is absorbed by the circulatory system and recycled for energy. The fatty acids, which are hydrophobic, are carried by transport proteins or chaperones, predominantly albumin, and trafficked to the liver, where they are processed as any other fatty acid – including fatty acids from food. Any unmetabolized triglycerides are bound to carrier proteins or lipoprotein complexes and become part of the total body lipoprotein pool.

Source:  “Fat Cell Clearance”, http://www.ultrashape.com/fat_cell_clearance.aspx

Liposonix

Medicis announced acquisition of LipoSonix, Inc. in July 2008.  LipoSonix only recently launched its first product in Europe and is still in the process of developing its European customer base.  The LipoSonix system is not cleared for sale or use in the United States.

The LipoSonix system focuses high intensity ultrasound at specific depths within subcutaneous adipose tissue (1.1 cm to 1.8 cm), without harming the skin or underlying tissues and organs. This causes thermal coagulation of adipose tissue within the focal zone of the ultrasound beam. Damaged tissue and released triglycerides are engulfed and removed by macrophages that are drawn to the treated area by chemotactic signals. The lipid-laden macrophages then move through the lymphatic system to the liver, where the lipids are processed by the body’s normal biochemical pathways. Once processed by the liver, the energy from the lipids may be used by the body directly or, as with any fat, may be stored by the body in other adipose tissue if the energy is not required immediately. Adipose tissue that is destroyed in the treated area are no longer available to store fat. The damaged tissue in the treated area is reabsorbed over a period of approximately 8 to 12 weeks, which can yield an aesthetic body-contouring effect.

High Intensity Focused Ultrasound (HIFU) relies on the same principles as conventional ultrasound:

HIFU propagates easily through living tissue. If the ultrasound beam carries sufficient energy and is brought into a tight focus, the energy within the focal zone can cause a local rise in temperature of sufficient magnitude to cause tissue necrosis.

-  HIFU relies on the fact that, above a threshold of 56°C (for 1 second), irreversible cell death occurs through coagulative necrosis.
-  Targeted tissue necrosis occurs without damaging intervening or surrounding tissues.
-  Energy levels greater than 1000 W/cm2 are able to induce cell death through focused and controlled thermal coagulation, leading to the effective elimination of the targeted fat.

Ultrashape

UltraShape uses a focused ultrasound beam directed towards the subcutaneous fat layer, causing a mechanical rather than a thermal effect to avoid adverse skin effects. This process selectively causes the disruption of fat cell membranes, leaving blood vessels, peripheral nerves and connective tissue intact. Triglycerides from the fat cell are released into the interstitial fluid between the cells, activating metabolic pathways that direct the water-insoluble molecules through the circulatory system.

Source:  Hercogova, Jana.  “Clinical Applications for Ultrashape” http://www.ultrashape.com/hercogova.aspx

The UltraShape fat reduction and body contouring system meets your patients’ need for a non-invasive, convenient way to reduce localized fat deposits and body circumference. The UltraShape system is the first scientifically and clinically proven non-invasive fat reduction and body contouring solution to selectively target and immediately disrupt unwanted fat.

-  Focused ultrasound energy: delivered only to tissue within a precise focal volume at a controlled depth.
-  Non-thermal, pulsed energy: no temperature increase.
-  Selective, mechanical effect: only fat cells are destroyed while skin, blood vessels, nerves and connective tissues remain unharmed.

The pulsed acoustic waves of ultrasonic energy converge in a confined focal volume causing non-thermal, mechanical disruption of fat cells. Histology confirms fat cell disruption while surrounding structures exposed to these effects remain unharmed.

Precision and safety are reinforced by an integrated acoustic contact sensor, which provides real-time feedback to ensure proper transducer-to-skin contact and efficient energy delivery to the treatment area. In addition, the advanced tracking and guidance software ensures complete and homogeneous energy delivery providing smooth, uniform body contouring results.

Source:  http://www.ultrashape.com/technology.aspx

The pulsed acoustic waves of ultrasonic energy converge in a confined focal volume causing non-thermal, mechanical disruption of fat cells. Histology confirms fat cell disruption while surrounding structures exposed to these effects remain unharmed.

Precision and safety are reinforced by an integrated acoustic contact sensor, which provides real-time feedback to ensure proper transducer-to-skin contact and efficient energy delivery to the treatment area. In addition, the advanced tracking and guidance software ensures complete and homogeneous energy delivery providing smooth, uniform body contouring results.

Other Body Contouring, Note Specifically Circumference Minimization  (Cellulite Treatments etc.)

Certain technologies are most suited to treating cellulite.  Cynosure’s Triacitve and Syneron’s Velashape have been more heavily marketed as cellulite treatments, rather than liposuction alternatives.

Velashape

Syneron’s Velashape system combines bi-polar radiofrequency (RF), infrared light energy, plus vacuum and mechanical massage. The “precise” heating ensures a safe, effective, fast treatment with no downtime.

Vacuum and specially designed rollers for the mechanical massage smooth out the skin to facilitate safe and efficient heat energy delivery. The net result increases the metabolism of stored energy, increases lymphatic drainage and reduces or shrinks the size of the actual fat cells and fat chambers.  In a clinical multi-center study, 85% of the treated areas have reported Circumferential Reduction of thighs of at least 1cm; ranging up to 7.2cm in reduction.

The heat from the RF and infrared light elements of the VelaShape device stimulate the energy “trapped” in the skin’s adipocytes, causing them to gradually shrink. Those are the cells, that form cellulite, so as they shrink, so do the unwanted pockets of cellulite, improving the skin’s contour.

While VelaShape’s heat works on reducing the fat cells, the device’s mechanical rollers manipulate and smooth out the skin.

In addition to minimizing cellulite dimpling, VelaShape reduces the circumference of the treated thighs—by an average of about an inch, according to studies.

The U.S. Food and Drug Administration has approved VelaShape (and its earlier incarnation, VelaSmooth) for the treatment of cellulite on the thighs.

Source:  http://www.cellulite-treatment.com/velashape.aspx

Laser and Ultrasound Liposuction References

Key Reference

Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006.
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Bond L.J., Cimino W.W. “Physics of Ultrasonic Surgery Using Tissue Fragmentation: Part II,” Ultrasound in Medicine and Biology 1996; 22:101-118.

Cimino W.W., Bond L.J. “Physics of Ultrasonic Surgery Using Tissue Fragmentation: Part 1,” Ultrasound in Medicine and Biology 1996; 22:89-100.

Cimino W.W. “The Physics of Soft Tissue Fragmentation Using Ultrasonic Frequency Vibration of Metal Probes,” Clinics in Plastic Surgery 1999; 26:447-461.

Cimino W.W. “Ultrasonic Surgery: Power Quantification and Efficiency Optimization,” Aesthetic Surgery Journal 2001; 21:233-240.

Cimino W.W. “Ultrasound-Assisted Lipoplasty: Past, Present, and Future,” Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p. 225-228.

Cimino W.W. “VASER-Assisted Lipoplasty: Technology and Technique,” Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Berlin, Germany, 2006, p. 239-244.

De Souza Pinto E.B., Federico R., et. al. “Lipomioplasty with VASER: A New Approach to Body Contouring,” Innovations in Plastic and Aesthetic Surgery, Editors M. Eisenmann-Klein and C. Neuhann-Lorenz, Springer-Verlag, Berlin, Germany, 2008, p. 433-442.

Di Giuseppe A. “Breast Reduction with Ultrasound-Assisted Lipoplasty,” Plastic and Reconstructive Surgery 2003; 112:71-82.

Di Giuseppe A. “Mastopexy (Breast Lift) with Ultrasound-Assisted Lipoplasty,” Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p. 254-257.

Di Giuseppe A. “Ultrasound-Assisted Lipoplasty for Breast Reduction,” Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p. 415-424.

Di Giuseppe A. “Ultrasound-Assisted Lipoplasty for Face Contouring with VASER,” Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p. 245-253.

Di Giuseppe A. “Ultrasound-Assisted Lipoplasty: Physical and Technical Principles,” Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p. 229-238.

Di Giuseppe A. “Ultrasound-Assisted Liposuction for Gynecomastia,” Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p. 474-480.

Di Giuseppe A., Commons G. “Face and Neck Remodeling with Ultrasound-Assisted (VASER) Lipoplasty,” Simplified Facial Rejuvenation, Editors M.A. Shiffman, S.J. Mirrafati, S.M. Lam, and C.G. Cueteaux, Springer-Verlag, Berlin, Germany, 2008, p. 137-148.

Di Giuseppe A., Wolters M., et. al. “HIV Lipodystrophy Treatment (Buffalo Hump) with VASER Ultrasound-Assisted Lipoplasty,” Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p. 554-562.

Fodor P.B., Cimino W.W., et. al. “Suction-Assisted Lipoplasty: Physics, Optimization, and Clinical Verification,” Aesthetic Surgery Journal 2005; 25:234-246.

Frank P.J. “Advances in Fat-emulsifying Technologies,” US Dermatology Review 2007; 25-26.

Garcia O., Nathan N. “Comparative Analysis of Blood Loss in Suction-Assisted Lipoplasty and Third-Generation Internal Ultrasound-Assisted Lipoplasty,” Aesthetic Surgery Journal 2008; 28: 430-435.

Hoyos A.E., Millard J.A. “VASER-Assisted High-Definition Liposculpture,” Aesthetic Surgery Journal 2007; 27:594-604.

Jewell M.L. “Innovation in Plastic and Aesthetic Surgery Lipoplasty,” Innovations in Plastic and Aesthetic Surgery, Editors M. Eisenmann-Klein and C. Neuhann-Lorenz, Springer-Verlag, Berlin, Germany, 2008, p. 443-453.

Jewell M.L., Fodor P.B., De Souza Pinto E.B., Al Shammari M.A. “Clinical Application of VASER-Assisted Lipoplasty: A Pilot Clinical Study,” Aesthetic Surgery Journal 2002; 22:131-146.

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