Gynoid Lipodystrophy Treatment and Other Advances on Laser-Assisted Liposuction

Keywords:laser, treatment, liposuction,  Time:20-11-2015

1. Introduction
Moreover, excessive obesity could be harmful for the health. Therefore, removal of the excess adipose tissue to keep the perfect shape and maintain a healthy physical state is now a common pursuit. Many methods have been used to treat the local adiposis and general obesity, including diet, medication, exercise and liposuction. For the purpose of improving the body contour, liposuction is the most widely used due to its long lasting result and positive effect. Over the past 30 years, liposuction has become an increasingly popular procedure and one of the most frequent aesthetic surgical operations.  At the earlier stage of the liposuction in the 1980s, the operation was usually performed as a hospital in-patient procedure, under general anesthesia and often required blood transfusion due to the blood lost during the operation. The procedure was usually related to a lot of potential complications. In 1988, Klein [1] published his important scientific contribution on the tumescent technique, administering large quantities of very dilute buffered lidocaine and epinephrine which could significantly reduce intra-operative bleeding and post-operative ecchymoses [2]. Although Klein’s tumescent technique dramatically improved the safety and recovery of patients, it has some shortages and the complications after liposuction, including bleeding, pain, operative trauma, slow recovery with weeks down time to the patients, and hard work for the surgeons.  On the other hand, Liposuction can work well for treating large areas of adiposis with thicker layers and looser texture, but it is less effective for the compact adipose tissues found in some localized positions such as the neck, in secondary procedures or in cases of gynecomastia. The adiposis in these locations consists of firm fibrous connective tissue and compact adipose tissues, which makes conventional liposuction more difficult to perform. It is difficult to insert and move the suction cannula within the compact tissues, and the compact adipose tissues are not easily aspirated. If force is exerted repeatedly, it causes great damage to the tissues. For these reasons, surgeons are continuing to refine the procedures and seek more advanced procedures with less injury, shorter down time, and more effective, such as interventional ultrasound-assisted liposuction [3-5], external ultrasound-assisted lipoplasty [6] and power-assisted lipoplasty [7]. In the search for a better solution, laser lipolysis was used to treat localized adiposis instead of conventional liposuction. Laser is an important innovation and has become a popular device in surgery, which is mainly used to treat hemangioma, tattoo, pigmentation, scars and so on. By its thermal effects on the tissue, laser was also studied on the liposlysis. From the 1990s, several papers have discussed the effects and results of different types of lasers on adipose tissues. Apfelberg [8-10] was beginning to study laser-assisted liposuction; this preliminary investigation utilized a YAG optical fiber contained within a liposuction cannula. The investigators concluded that no clear benefit was demonstrated with the laser. Since FDA did not approve the technique, the researchers did not pursue the study. In the late 1990s, Neira and colleagues began studying the effects of low-level laser on adipose tissue [11-14].  At the same time, Blugerman [15] /, Schavelzon [16] and Goldman [17-18] were studying 1064 nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser on the lipolysis. They found that the medical fiber optics could cause adipocytes lysis effectively and had less side-effect. The characteristics of laser lipolysis are less intra-operative blood loss, less post-operative ecchymoses and improved skin tightening and skin re-draping during the recovery process [19, 20]. The procedures of lipolysis made small tunnels in the adipose tissue, resulted in small blood vessels coagulation and coagulation of reticular dermis [21-24]. The accumulated experience and scientific publications of the senior author and colleagues during the last 10 years enhance the knowledge about laser and tissue interactions, as well as the possibility of obtaining not only fat-cell disruption but also tissue tightening, supports the efficacy and safety of subdermal laser-assisted use in the body and facial treatments. Current laser-assisted liposuction is designed to provide more selective adipose damage, facilitate fat removal, enhance hemostasis, and increase tissue tightening. Recent advances demonstrating the use of the laser in direct contact with targets like the fat, sweat glands, vessels and dermis layers opened up new applications on different conditions. Although some negative or neutral views have been reported, most of the results have shown that laser lipolysis has the advantages of less bleeding, pain, and edema, a quicker recovery and better comfort. Most of the patients obtained satisfactory results, with significant reduction of their adiposes. The clinical results have proved that laser lipolysis is an effective therapy for these patients. In subsequent histologic studies, the findings showed that the adipose cells had been damaged and ‘‘melted.’’ Their cell membranes had shrunk, curled, or ruptured, leading to loss of integrity and shape of the cells, with consequent loss of cellular content. The purpose of the chapter is to demonstrate the evolution and new indications of laser lipolysis as well as new concepts and trends related to this technique. Treatment of localized fat, skin and tissue flaccidity, cellulite, lipomas, hyperhidrosis and osmidrosis, vascular alterations, treatment of complications related to permanent fillers, combine treatments with traditional surgeries and new indications will be described in the chapter.

2. Laser biology

A laser (light amplification by stimulated emission of radiation) is a device which generates a coherent beam of stimulated emission light resulted from a quantum mechanical effect. The first working laser was a ruby laser with a wavelength of 694nm, invented by Maiman in 1969, who later received the Albert Einstein Award. There are several properties of laser beams: 1) monochromatic: all of the waves of a laser having the same wavelength; 2) collimated: a laser generally emits photons in a narrow direction, and the waves parallel and have minimal variation in convergence or divergence; 3) coherent: describes the property of having waves that are in phase with on another in both space and time; 4) high brightness: a laser light can be highly intense, and to be focused to very high intensities and used for cutting, burning or even vaporizing materials.  The tissue interactions produced by lasers are 1）photothermal effect: converting light energy into heat energy, which then heat tissue up to be coagulated and even be vaporized; 2) photochemical effect: the light of laser making target cells to produce chemical reactions, such as photodynamic reactions; 3) photobiological effect, 4) electromechanical effect: dielectric breakdown in tissue caused by shock wave plasma expansion resulting in localized mechanical rupture. The processes of laser after arrival on the tissue are transmission, absorption, reflection, and scatter. There are several important parameters determining the action level of laser on the tissue: 1) wavelength: it is the primary parameter of the laser, which affects the absorption of laser by tissues; 2) power density: related to the power and spot size, and plays a critical role in determining tissue interaction; 3) exposure time: the more exposure time, the more energy acted on the tissue; 4) laser types: Qswitched, pulsed and continuous wave (CW), which was used for different purposes clinically. Laser is an important innovation and has become a popular device in surgery. Nd:YAG laser produces a beam in the near-infrared region, with a wavelength of 1064nm. Its main effect on the tissue is coagulation, which could be used to destroy tumors or to coagulate vascular vessels, for the treatment of hemangioma, tattoo, pigmentation, scars and so on. The Nd:YAG laser could be transmitted through flexible quartz fiber optics, making its use in endoscopy possible. The Nd:YAG laser beam scatters in tissue to create the coagulation and can also produce retrograde scatter. The YAG lasers using in the lipolysis usually have high output power of 6 to 30 watts, which are highly dangerous of safety classes IV. Because of its danger, special eye protection is necessary. All personnel should wear glasses with side panels or goggles that are appropriated for the laser in use, since the eye is the most delicate organ commonly exposed to laser injury. Green filter glass is needed for the Nd: YAG laser. Moreover, during tissue vaporization, smoke is produced, which contains nonviable particles, and so should be avoided to be breathed in.

3. Histological study of laser lipolysis

Observed by the optical microscope and SEM, lipocytes were separated into fat lobules in normal adipose tissue (Fig. 1-3). They were spherical, surrounded by vessels and connective tissues. Small nucleus was located at the edges of cells. After irradiated by the laser, the adipose tissues became loose and messy, blank areas were observed that the closer to the blank areas the more serious destruction appeared. Fibers were broken. Some crater-like depressions were seen. Lipocytes shrunk, broke and melted, and a large number of lipid droplets leaked. Connective tissues melted, twisted and adhered.

3. Fundaments of laser lipolysis

As the laser has the biothermal effect on tissues, it is expected can overcome the shortage of traditional surgical method, disrupt adipose tissues selectively, shorten surgery and recovery time, enhance hemostasis, promote tissue retraction, and reduce complications. From the 1990s, several papers have discussed the effects and results of different types of lasers on adipose tissues. The accumulated experience and scientific publications of the authors and colleagues enhance the knowledge about laser and tissue interactions, as well as the possibility of obtaining not only fat-cell disruption but also tissue tightening, supports the efficacy and safety of subdermal laser-assisted use in the body and facial treatments. Current laser-assisted liposuction is designed to provide more selective adipose damage, facilitate fat removal, enhance hemostasis, and increase tissue tightening. Recent advances demonstrating the use of the laser in direct contact with targets like the fat, sweat glands, vessels and dermis layers opened up new applications on different conditions.  Adipose tissue distribution is dependent on genetic and environmental factors. The total and regional masses of adipose tissue are dependent on the number of adipocytes as well as their degree of filling with depot fat. [25] The subcutaneous tissue consists of a superficial and deep adipose layer. The superficial adipose layer is contained within organized, compact fascial septa. The deep adipose layer demonstrates regional variations, but is contained within a relatively loose, less organized, and more widely spaced fascial septa. Energy substrate, storage of lipids and vitamins, protection of vital organs, physical support and insulation, maintenance of serum lipids, source of hormones and generation of heat are some of important functions related to the adipose tissue. The adipocyte represents one of the most important targets in laser lipolysis process. These adipose cells store lipids and are normal constituents of connective tissue. Adipose tissue is composed mostly of fat cells organized into lobules. Lobules of fat are separated and supported by loose connective tissue called septa. Dermis represents another important target to be treated in the laser-assisted liposuction (laser lipolysis). The primary function of the dermis is to sustain and support the epidermis. Dermis is a complex structure and is composed of two layers, the more superficial papillary dermis and the deeper reticular dermis. The papillary dermis is thinner, consisting of loose connective tissue and some collagen. The reticular dermis consists of a thicker layer of dense connective tissue containing larger blood vessels, closely interlaced elastic fibers, fibroblasts and coarse bundles of collagen fibers arranged in layers parallel to the surface. Other targets related to this surgical procedure are represented by small blood vessels, eccrine and apocrine glands, fibrous tissue presented in cellulite and body regions previously submitted to surgical procedures like liposuction.The mechanism of action on a cellular level is due to a specific laser-tissue interaction that is defined by the process of selective photothermolysis [26]; some features of this interaction are wavelength-dependent and some are independent of wavelength used. The progresses of laser lipolysis are: 1. melting adipose tissue into liquid state by heating  adipocytes; 2. heating adipocytes to disrupt their membrane and allow extracellular drainage and facilitated suctioning; 3. heating collagenous fibrous septae and reticular dermis for enhanced tissue tightening; 4. coagulating microvasculature to improve hemostasis and to reduce postoperative bleeding. 5. minimal intervention of the procedure improving rapid recovery.

4. Instruments of laser lipolysis

The instrument of laser lipolysis consists of 3 main parts: Medical Laser Fiber machine, transfer system, and control system.

4.1 Laser machine

The effects of laser-assisted lipolysis are caused by photothermal energy as well as photomechanic effect. The various wavelengths for laser-assisted liposuction have been selected based on the theory of selective photothermolysis.

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