1. Laser Liposuction: A 2 Year ExperienceLaser Liposuction: A 2 Year Experience Rex Moulton-Barrett, MD Plastic & Reconstructive Surgery Alameda and Brentwood, Ca

2. Paradoxes of ProgressParadoxes of Progress SirSir Peter MedawarPeter Medawar technology and science advance in a sinusoidal patterntechnology and science advance in a sinusoidal pattern QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. Discoveries arise through necessity & create need for newDiscoveries arise through necessity & create need for new technologytechnology When technology advances without a scientific basisWhen technology advances without a scientific basis be cautiousbe cautious 3. Current Techniques of LipolysisCurrent Techniques of Lipolysis Topical anti-cellulite creamsTopical anti-cellulite creams Oral anti-cellulite medicationOral anti-cellulite medication Trans-cutaneous laser lipolysisTrans-cutaneous laser lipolysis ultrasonic lipolysisultrasonic lipolysis Sub-cutaneous injection lipolysisSub-cutaneous injection lipolysis Subcutaneous mechanical lipolysis aka liposuctionSubcutaneous mechanical lipolysis aka liposuction Subcutaneous Liposuction with:Subcutaneous Liposuction with: UltrasonicUltrasonic lipolysislipolysis VibrationVibration lipolysislipolysis HydroHydro lipolysislipolysis RadiofrequencyRadiofrequency lipolysislipolysis LaserLaser lipolysislipolysis 4. Topical Anti-CelluliteTopical Anti-Cellulite CreamsCreams > 30 products commercially available> 30 products commercially available Only 1 study with blinding: 8 pts onlyOnly 1 study with blinding: 8 pts only Not effectiveNot effective in double blind placebo studyin double blind placebo study Top product :Top product : RevitolRevitol 3 most common agents:3 most common agents: retinol, caffeine, aminophyllineretinol, caffeine, aminophylline Ms. Sixty Jeans:Ms. Sixty Jeans: retinol capsules rupture with wear!retinol capsules rupture with wear! QuickTime and a decompressor are needed to see this picture. 5. Oral anti-cellulite MedicationOral anti-cellulite Medication Cellasene: Fucus vesiculolus or bladderwrack & clover extract, gingko, grapeseed, 240mig iodine, primerose oil and fish oil, lecithin Published studies, New York 1998 and London 1999: placebo and double blinded found no difference 6. Cutaneous Injection LipolysisCutaneous Injection Lipolysis Self administered 10 week kits ($540) LipodissolveSelf administered 10 week kits ($540) Lipodissolve AKA:AKA: LipostabilLipostabil Each kit contains:Each kit contains: 5mls: 1250 mg5mls: 1250 mg Phosphatidylcholine+deoxycholatePhosphatidylcholine+deoxycholate 10mls: 14 mgs Tiratricol: Triiodothyroacetic acid10mls: 14 mgs Tiratricol: Triiodothyroacetic acid 10mls: 2% Procaine HCL10mls: 2% Procaine HCL 10 x 5 ml syringes10 x 5 ml syringes EMLA creamEMLA cream 10 x 30 g needles10 x 30 g needles QuickTime and adecompressor are needed to see this pic 7. Injectional Lipolysis for LipomasInjectional Lipolysis for Lipomas 30 lipomas in 10 patients: Germany 200730 lipomas in 10 patients: Germany 2007 4 Phospatidylcholine injections/lipoma/6-8 wk intervals4 Phospatidylcholine injections/lipoma/6-8 wk intervals 46% reduction in sonographic size46% reduction in sonographic size 27% hematoma complication27% hematoma complication 40% complained of pain over injection site40% complained of pain over injection site Bachara, etal, 2007. J Cut Surg 10(4), 155-9.Bachara, etal, 2007. J Cut Surg 10(4), 155-9. 8. Sub-cutaneousSub-cutaneous Laser & Liposuction:Laser & Liposuction: 88 companiescompanies From 2006-2009 Name Wavelength (nm) Pulse Freq Pulse Power Max power output Fiber size Pulse width/duration Simultaneous or staged lipo Date FDA cleared Osyris LipoControl 980nm diode laser staged 2009 pending CoolTouch Cool-Lipo 1320 Nd:YAG 20-50 Hz 15 Watts .32-2mm 100 micsec simultaneous January 2008 Eleme SmoothLipo 980nm continuous Cynosure Smart-Lipo 1064 &1320 Nd:YAG 40 Hz (aiming beam- 3mW) 6, 12, 18 watt .35mm .4 mm, .6mm 150,200, 250 mic sec staged November 2006 Palomar SlimLipo 924 & 975 diode laser continuous N/A 15-25 Watt & 40 watt. 1.5 mm continuous staged April 2008 Sciton ProLipo 1064 & 1319 Nd:YAG 1-50Hz 5-10 watts 5-25 Watts 0.6 and 1 mm 10-100 microsec staged July 2007 Lutronic AccuSculpt 1444nm Nd:Yag 40 Hz 175 mJ 7 W 0.6mm 100-150 micsec staged November 2008 Syneron LipoLite 1064 Nd:YAG 50Hz 800mJ 2 pulsed energy levels 12 Watts .550 mm 100-800 micsec staged May 2008 9. Lutronic AccuSculpt 1444nm Laser Assisted LiposuctionLutronic AccuSculpt 1444nm Laser Assisted Liposuction Purported to be the greatest fat absorption coefficient of laser assistedPurported to be the greatest fat absorption coefficient of laser assisted devices: > 8 x absorption 1064 and 1320nmdevices: > 8 x absorption 1064 and 1320nm Relies on photo-acoustic properties & less photo-thermic action for lipolysisRelies on photo-acoustic properties & less photo-thermic action for lipolysis Because of this requires less power and therefore less thermal damageBecause of this requires less power and therefore less thermal damage Theoretically, should have high photo-thermic injuryTheoretically, should have high photo-thermic injury, purported opposite, purported opposite Competing chromophores: ieCompeting chromophores: ie dermal waterdermal water should limit power usedshould limit power used 10. Slimlipo:Palomar Aspire 924 & 975 nmSlimlipo:Palomar Aspire 924 & 975 nm YAG Laser Assisted LiposuctionYAG Laser Assisted Liposuction Approved for laser lipolysis April, 2008Approved for laser lipolysis April, 2008 Dual Diode laserDual Diode laser 924nm high preference for fat absorption924nm high preference for fat absorption 975nm high preference for dermis975nm high preference for dermis Purported continuous wave delivery withPurported continuous wave delivery with 20 times greater area of thermolytic20 times greater area of thermolytic lipolysis over other laser lipolysislipolysis over other laser lipolysis QuickTime and a decompressor are needed to see this picture. QuickTime and a decompressor are needed to see this picture. QuickTime and a decompressor are needed to see this picture. Slimlipo 1064nm Histological zone of thermal effect 11. Cooltouch CoolLipo 1320nm Nd:YAGCooltouch CoolLipo 1320nm Nd:YAG Laser Assisted LiposuctionLaser Assisted Liposuction Delivery fiber diameter 320-Delivery fiber diameter 320-2000 microns2000 microns Designed for small area: neck and chinDesigned for small area: neck and chin New CoolBlue Duet HandpieceNew CoolBlue Duet Handpiece :: ablates and simultaneousablates and simultaneous aspirationaspiration with 2.5 mm cannulae ( June 2008 )with 2.5 mm cannulae ( June 2008 ) 12. SmartLipo 1064nm Nd:YagSmartLipo 1064nm Nd:Yag SmartLipo MPX: 1064+1320nmSmartLipo MPX: 1064+1320nm SmartLipo Triplex:1064+1320+1444SmartLipo Triplex:1064+1320+1444 Laser Assisted LiposuctionLaser Assisted Liposuction Originally Italian Deka company: termed lipolysis, designed for up toOriginally Italian Deka company: termed lipolysis, designed for up to 500cc500cc FDA approved 2006 CynosureFDA approved 2006 Cynosure 1, 734 pts Brazil: 1 burn, 1 seroma, all < 500 mls, 300micron fiber,1, 734 pts Brazil: 1 burn, 1 seroma, all < 500 mls, 300micron fiber, 1mm metal cannulae, tumescent technique ( Goldman, 2002)1mm metal cannulae, tumescent technique ( Goldman, 2002) Commonest complaintCommonest complaint undercorrectionundercorrection especially larger treatmentespecially larger treatment areasareas 82 pts Brazil: submental area:82 pts Brazil: submental area: similar overall results with traditionalsimilar overall results with traditional liposuction except he noted less postoperative bleedingliposuction except he noted less postoperative bleeding ( Goldman,( Goldman, 2006)2006) New 1mm fiber and hand-piece measures tip temperature andNew 1mm fiber and hand-piece measures tip temperature and regulates energy provided to avoid overheating and skin injuryregulates energy provided to avoid overheating and skin injury Maximum power MPX up to 30 Watts 1064nm, 16 Watts 1320nmMaximum power MPX up to 30 Watts 1064nm, 16 Watts 1320nm 13. Syneron Lipolyte 1064nm with Nd:YagSyneron Lipolyte 1064nm with Nd:Yag Laser Assisted LiposuctionLaser Assisted Liposuction Up to 12W, 100-800 mcsecsUp to 12W, 100-800 mcsecs Uses 2 pulses:Uses 2 pulses: 1J: photo-thermal> 700mcsec+>1J: photo-thermal ie low frequency and high energy: thermalie low frequency and high energy: thermal 0.55 mm diameter fiber0.55 mm diameter fiber Disposable handpiece/cannulaeDisposable handpiece/cannulae Recommended for < = 15x20cm zonesRecommended for < = 15x20cm zones 14. Sciton: ProLipo 1064+1319nm Nd:YagSciton: ProLipo 1064+1319nm Nd:Yag Laser Assisted LiposuctionLaser Assisted Liposuction Subcutaneous laser lipolysis followed by liposuctionSubcutaneous laser lipolysis followed by liposuction 600 -1000 micron fiber, inside a 14 or 18g cannulae600 -1000 micron fiber, inside a 14 or 18g cannulae Choice of 2 wavelengths:Choice of 2 wavelengths: 10641064 & 1319 nm or blending both& 1319 nm or blending both Maximum power 1064nm & 1319nm 40 W, RR up 50 HzMaximum power 1064nm & 1319nm 40 W, RR up 50 Hz Pulse duration 10-100 microsecondsPulse duration 10-100 microseconds MayMay combine with transcutaneous intense pulse light:combine with transcutaneous intense pulse light: Skin -TyteSkin -Tyte 800-1400nm800-1400nm BBL: Broad Band LightBBL: Broad Band Light 15. Trans-cutaneousTrans-cutaneous Laser & Non-Laser Assisted Lipolysis:Laser & Non-Laser Assisted Lipolysis: >13>13 companiescompanies From 2002-2011 Company and product name Type of product Action FDA clearance Erchonia Niera 635nm Dual Diode laser Staged lipolysis before liposuction 2004 Erchonia Zerona 650nm Diode Laser Lipolysis alone April 2008 Eleme SmoothShapes 650 nm laser and 915nm IPL Cellulite reduction January 2008 Cutera Titan: V, XL,S Infrared 1100- 1800 nm Skin tightening 2004 Palomar LuxDeepIR Infrared Skin tightening Feb 2007 Sciton BBL IPL: 800- 1400nm Skin tightening 2006 Solta Medical Thermage IPL Skin tightening 2002 Syneron VelaShape II RF Cellulite reduction August 2007 Alma Lasers Accent XL RF: Uni / Bi - polar Skin tightening April 2007 BTL Exilis RF ans U/S Skin tightening FDA pending General Project Slim Project, Med Sculpt, Med Contour External 2 wave U/S and massage Cellulite Reduction & lipolysis November 2006 Medicis Liposonix High intensity focused U/S Lipolysis alone Pending 2011 ? MedixSysteme Ultracontour High intensity focused U/S and U/S vasodilation Lipolysis Alone Pending 2009 Zeltiq Aesthetics Cryolipolysis Lipolysis alone Pending 2009 LASER IPL RF U/S CRYO 16. Science Behind Specific Wavelength Choice forScience Behind Specific Wavelength Choice for Laser Assisted LiposuctionLaser Assisted Liposuction Little information to support a given wavelength: either photoacousticLittle information to support a given wavelength: either photoacoustic or photothermolytic, comparing histological or clinical dataor photothermolytic, comparing histological or clinical data :: 900-930, 1190-1220, 1700-1730, or 2280-2350 nm900-930, 1190-1220, 1700-1730, or 2280-2350 nm Fresh ex-vivo cadaveric abdominoplasty pannus lasered with 1064, 1320,Fresh ex-vivo cadaveric abdominoplasty pannus lasered with 1064, 1320, 2100 nm using a 0.320mm fiber2100 nm using a 0.320mm fiber Control: mechanical fiber trauma aloneControl: mechanical fiber trauma alone Fiber withdrawn at 1mm per second, single passFiber withdrawn at 1mm per second, single pass No clear fat liquefaction seen histologicallyNo clear fat liquefaction seen histologically Difficult to capture photoacoustic effect histologicallyDifficult to capture photoacoustic effect histologically Thermal damage dependent on power for each wavelengthThermal damage dependent on power for each wavelength Diameter of damage 1-5mm proportionate to power/pulseDiameter of damage 1-5mm proportionate to power/pulse Koury et al, 2008; Laser Surg Med 40(6):402-6Koury et al, 2008; Laser Surg Med 40(6):402-6 17. Liposuction alone vrs 1064nm subcutaneousLiposuction alone vrs 1064nm subcutaneous laser assisted liposuctionlaser assisted liposuction Few comparative clinical studiesFew comparative clinical studies Laser assisted Liposuction describedLaser assisted Liposuction described 1994: (Affelberg)1994: (Affelberg):: inconclusive benefitinconclusive benefit using 1064nm over traditional liposuctionusing 1064nm over traditional liposuction Liposuction vrs Laser1064nm /liposuction randomised, controlled study inLiposuction vrs Laser1064nm /liposuction randomised, controlled study in Chile, the latter causes:Chile, the latter causes: less painless pain (p > 0.0001 t test),(p > 0.0001 t test), less bloodless blood within the aspirate,within the aspirate, averageaverage duration of surgery 25% longerduration of surgery 25% longer (p>0.0005):(p>0.0005): otherwise all other parameters are equal:otherwise all other parameters are equal: swelling, bruising, skin tightening, contour improvementswelling, bruising, skin tightening, contour improvement (Prado, et al, 2006)(Prado, et al, 2006) 82 pts Brazil: submental area:82 pts Brazil: submental area: similar overall resultssimilar overall results with traditional liposuctionwith traditional liposuction exceptexcept he noted less postoperative bleedinghe noted less postoperative bleeding (Goldman, 2006)(Goldman, 2006) 18. 1064nm Laser lipolysis with1064nm Laser lipolysis with liposuctionliposuction versusversus no liposuctionno liposuction No clinical studies sitedNo clinical studies sited No reports comparing liposuction with vrs no liposuctionNo reports comparing liposuction with vrs no liposuction Lysed fat is locally inflammatoryLysed fat is locally inflammatory Does leaving lysed fat cause more swelling ?Does leaving lysed fat cause more swelling ? 19. Trans-cutaneous Laser Assisted Liposuction VersusTrans-cutaneous Laser Assisted Liposuction Versus Liposuction AloneLiposuction Alone Few comparative studiesFew comparative studies Erchonia Niera 635nm Dual Diode, 14 mWattErchonia Niera 635nm Dual Diode, 14 mWatt Reduces swelling & bruisingReduces swelling & bruising (Neira, et al, 2002)(Neira, et al, 2002) Speeds up rate of extraction by liposuction:Speeds up rate of extraction by liposuction: 40% faster, after 6 minute of application40% faster, after 6 minute of application (Jackson, et al, 2004)(Jackson, et al, 2004) 50% greater volume of lipolysis when tumescent solution50% greater volume of lipolysis when tumescent solution usedused 20. BBL & Prolipo Clinical ChoicesBBL & Prolipo Clinical Choices BBL: before or after laser liposuction ?BBL: before or after laser liposuction ? Laser lipolysis with and without liposuction ?Laser lipolysis with and without liposuction ? End-point of laser lipolysis ?End-point of laser lipolysis ? 21. Variables In Technique of BBL &Variables In Technique of BBL & Laser Lipolysis and LiposuctionLaser Lipolysis and Liposuction BBL settingsBBL settings and application method:and application method: passespasses Tumescent InjectionTumescent Injection: concentration & volume: concentration & volume Laser FiberLaser Fiber: size, settings, technique: depth/passes: size, settings, technique: depth/passes LiposuctionLiposuction: cannulae size, volume, end point: cannulae size, volume, end point Post procedure carePost procedure care: compression duration: compression duration 22. BBL Interchangeable FiltersBBL Interchangeable Filters Filters (nm)Filters (nm) 420 -420 - Blue lightBlue light 515 -515 - PigmentPigment 560 -560 - VascularVascular && PigmentPigment 590 -590 - VascularVascular && HairHair 640 -640 - VascularVascular && HairHair 695 -695 - HairHair 800 - 1400800 - 1400 - ST applicator *- ST applicator * Applications * 23. BBL: ControlledBBL: Controlled CoolingCooling Sapphire crystal contact coolingSapphire crystal contact cooling Provides timed before, during and after contact coolingProvides timed before, during and after contact cooling System sets skin temperature accurately from 0C to 30CSystem sets skin temperature accurately from 0C to 30C Includes 15 x 45, 15 x 15 or round 10 mm treatment areaIncludes 15 x 45, 15 x 15 or round 10 mm treatment area 24. Epidermis Dermis SkinTyte elevates subsurface temperature A subsurface layer is briefly heated The epidermis remains 12 C and dermis heats to 55 C Sciton SkinTyteSciton SkinTyte Chilled Sapphire Plate 12C 55C 25. Epidermis Dermis Denatured collagen causing immediate contraction Activated fibroblasts leads to long-term remodeling Sciton SkinTyteSciton SkinTyte 26. BBL Settings 27. ProLipo EquipmentProLipo Equipment liposuction cannulaeliposuction cannulae fiber and handlefiber and handle 28. Settings 29. Clinical Case Series: Case 1Clinical Case Series: Case 1 Patient information: age 39Patient information: age 39 Hispanic with Fitzpatrick III-IVHispanic with Fitzpatrick III-IV Unhappy with submental pannusUnhappy with submental pannus 30. Clinical series:Clinical series: Case 1 ( cont.)Case 1 ( cont.) BBL: submental 40J/cm2 3 second pulse 3 second post-cooling 12C cooling temp 3 passes one week laterProLipo: 20 ml 1% Lidocaine with 1:100,000 Epinephrine 0.6mm fiber 0.4 J/pulse 3000 Joules Repitition rate (RR) 30 No liposuction performed 31. Clinical Case Series: Case 1 (cont.)Clinical Case Series: Case 1 (cont.) Continued improvementContinued improvement 4-54-5 monthsmonths More swelling without liposuctionMore swelling without liposuctionBefore 6 months after 32. Clinical Series: CaseClinical Series: Case 22 Patient Information: age 45Patient Information: age 45 1 yr after facelift1 yr after facelift Unhappy with separation of submental platysmaUnhappy with separation of submental platysma & fat collections& fat collections ProLipo: 20ml 1% lido with 1:100,000 epiProLipo: 20ml 1% lido with 1:100,000 epi 3400 J3400 J total, RR 30, 2.5mm cannula,total, RR 30, 2.5mm cannula, 10ml liposuction10ml liposuction Followed by BBL ST:Followed by BBL ST: Unable to determine end -pointUnable to determine end -point 40 J/Cm240 J/Cm2 RR 30 HzRR 30 Hz 12C cooling, 3 seconds,12C cooling, 3 seconds,3 passes3 passes QuickTime and a decompressor are needed to see this picture. Before 3 Months after 33. Clinical Series: Case 3Clinical Series: Case 3 Pt. Information: 63 FPt. Information: 63 F Fitzpatrick IIFitzpatrick II unhappy with submental faty playtsma bandsunhappy with submental faty playtsma bands previous facelift with playtsma corseting 1 yr beforeprevious facelift with playtsma corseting 1 yr before BBL: ST:BBL: ST: 35 J/cm235 J/cm2, 30 Hz, 3 second cooling,, 30 Hz, 3 second cooling, 3 passes3 passes ProLipo:ProLipo: 15ml 1%lido with 1:100,00 epi15ml 1%lido with 1:100,00 epi 0.4 J/ pulse, 35 Hz,0.4 J/ pulse, 35 Hz, 3600 Joules3600 Joules LiposuctionLiposuction aspiration 10mlaspiration 10ml 2.5mm cannula2.5mm cannula ComplicationComplication:: small skin burn at cervico-mental anglesmall skin burn at cervico-mental angle just right of midline at platysma bandjust right of midline at platysma band Before 5 Months after 34. Clinical series: CaseClinical series: Case 44 Pt Information: age 48Pt Information: age 48 Fitzpatrick II-IIIFitzpatrick II-III Unhappy with submental & jowl fat andUnhappy with submental & jowl fat and platysma bandsplatysma bands BBL ST:BBL ST: 40 J/cm240 J/cm2 2 second post cooling2 second post cooling Cooling at 12 CCooling at 12 C Pulse width 5 secondsPulse width 5 seconds 3 passes3 passes ProLipo: 0.4J/pulseProLipo: 0.4J/pulse Freq 30 HzFreq 30 Hz 2000 Joules2000 Joules Liposuction:Liposuction: 14ml lidocaine & 1:100,000 epi14ml lidocaine & 1:100,000 epi 2mm liposuction cannulae2mm liposuction cannulae Aspiration volume 10mlAspiration volume 10ml Before 3 Months after 35. Clinical Series: Case 5Clinical Series: Case 5 Pt. information:Pt. information: 42F42F Unhappy with submental pannusUnhappy with submental pannus BBL:BBL:35J/cm235J/cm2 3 second passes3 second passes 3 second cooling: 12C3 second cooling: 12C 3 passes3 passes PropLipo: 20ml 1% lido with epiPropLipo: 20ml 1% lido with epi 1:100,0001:100,000 6mm cannulae .35J/cm26mm cannulae .35J/cm2 RR 30RR 30 2000J2000J Liposuction 2mm cannula 15mlsLiposuction 2mm cannula 15mls Before 7 Months after 36. Pt Information: 17 MPt Information: 17 M Unhappy with submentalUnhappy with submental pannuspannus BBL: ST:BBL: ST: 40J/cm240J/cm2 3.5 second pulse width3.5 second pulse width 12 C cooling12 C cooling 2 second cooling2 second cooling 3 passes3 passes ProlipoProlipo 0.35 J/pulse0.35 J/pulse RR 30RR 30 2400 J2400 J Liposuction: infusion 20mlLiposuction: infusion 20ml 1% lidocaine &1% lidocaine & 1:100,000 epi1:100,000 epi Aspiration 20mlAspiration 20ml Clinical Series: CaseClinical Series: Case 66 Before 3 Months after 37. Clinical Series: CaseClinical Series: Case 77 Patient Information: age 51Patient Information: age 51 Fitzpatrick IIFitzpatrick II Requesting reduction ofRequesting reduction of Submental fat pannusSubmental fat pannus BBL: 3 passesBBL: 3 passes 40J/cm240J/cm2 12C cooling temp12C cooling temp 5 second pulse width5 second pulse width 2 second post cooling2 second post cooling ProLipo: 13 ml 1% lido with epiProLipo: 13 ml 1% lido with epi 6mm fiber6mm fiber rate 40rate 40 12 watt12 watt 3 Jewels3 Jewels pulse energy 30pulse energy 30 234 seconds234 seconds total 2000 Jtotal 2000 J LiposuctionLiposuction 2mm cannulae lposuction2mm cannulae lposuction 10ml liposuction aspiration10ml liposuction aspiration Before 9 Months after 38. Clinical Series: Case 8Clinical Series: Case 8 Pt. information: 36 FPt. information: 36 F Unhappy with submentalUnhappy with submental laxity and fatlaxity and fat BBL ST:BBL ST: 45 J/cm245 J/cm2 3 second post cooling3 second post cooling Cooling at 12 CCooling at 12 C Pulse width 5 secondsPulse width 5 seconds 3 passes3 passes ProLipo:ProLipo: 30 ml infiltration30 ml infiltration 1064nm1064nm 6mm fiber6mm fiber 0.7J/pulse0.7J/pulse Freq 30 HzFreq 30 Hz 3,300 Joules3,300 Joules 25ml liposuction aspiration25ml liposuction aspiration Before 3 Months after 39. Pt Information 35 FPt Information 35 F c/o familial submentalc/o familial submental laxity and pannuslaxity and pannus BBL:BBL: 40J/cm240J/cm2 3 second exposure3 second exposure 2 seconds cooling2 seconds cooling Temp 15CTemp 15C 3 passes3 passes Prolipo: 0.4J/pulseProlipo: 0.4J/pulse RR 30,RR 30, 2412 J total2412 J total LiposuctionLiposuction 18 ml tumescent solution18 ml tumescent solution 2.5mm cannula2.5mm cannula 20ml aspiration20ml aspiration Clinical Series: Case 9Clinical Series: Case 9 Before 3 weeks after 40. Case 10Case 10 Before 11 Months after2 Months after 41. Results: Submental ST andResults: Submental ST and ProLipoProLipo Demographics and ClinicalDemographics and Clinical 10 pts aged from 17-6310 pts aged from 17-63 Between 2008-2009Between 2008-2009 longest follow-up 12 monthslongest follow-up 12 months 7/10 women7/10 women All unhappy with submental fat collection & laxityAll unhappy with submental fat collection & laxity 2/10 previous face lifts & developed laxity within 1 yr2/10 previous face lifts & developed laxity within 1 yr 42. Results: Submental ST and ProlipoResults: Submental ST and Prolipo ( cont. )( cont. ) 9/10 pts underwent BBL: ST prior to ProLipo9/10 pts underwent BBL: ST prior to ProLipo End-point: patient heat and or dyscomfort from STEnd-point: patient heat and or dyscomfort from ST Unable to tolerate more than 3 passesUnable to tolerate more than 3 passes Most common settings: 35-40J/cm2, 3.5 second pulseMost common settings: 35-40J/cm2, 3.5 second pulse width, 12-15 C cooling temp, 2-3 second post coolingwidth, 12-15 C cooling temp, 2-3 second post cooling 1/10 injected with local anesthetic before ST: patient1/10 injected with local anesthetic before ST: patient unable to help us with endpoint determination,unable to help us with endpoint determination, felt unsafe to use anesthetic prior to ST thereafter 43. Results: Submental ST and Prolipo ( cont. )Results: Submental ST and Prolipo ( cont. ) 0.6mm fiber passed through a single submental incision0.6mm fiber passed through a single submental incision No pre-tunneling & no cross-hatchingNo pre-tunneling & no cross-hatching Settings:Settings: 2000J total energy used in submental area2000J total energy used in submental area between 0.35-0.4 J/pulsebetween 0.35-0.4 J/pulse RR 30RR 30 End - point: Ease of fiber passageEnd - point: Ease of fiber passage Surface temperature measured by handSurface temperature measured by hand Total energy count 2000 JTotal energy count 2000 J 44. Results: Submental ST and Prolipo ( cont. )Results: Submental ST and Prolipo ( cont. ) 1/10 underwent laser without liposuction1/10 underwent laser without liposuction This patient developed significant local tissueThis patient developed significant local tissue reaction presumed secondary to not removingreaction presumed secondary to not removing the lysed fatthe lysed fat I felt it is better to remove the lysed fat cells 1/10 technical complication of skin injury1/10 technical complication of skin injury Complication was entirely preventable, surgeonComplication was entirely preventable, surgeon was attempting to divide a platysma band whichwas attempting to divide a platysma band which was adherent to the skin s/p faceliftwas adherent to the skin s/p facelift All 10 patientsAll 10 patients very satisfiedvery satisfied with resultswith results 45. Results: Submental ST and Prolipo ( cont.)Results: Submental ST and Prolipo ( cont.) No patients reported significant pain and did not require painNo patients reported significant pain and did not require pain medication, all patients were given prophylactic antibiotics inmedication, all patients were given prophylactic antibiotics in view of the procedure being performed in an office settingview of the procedure being performed in an office setting 7/10 patients requested oral sedation with a combination of7/10 patients requested oral sedation with a combination of diazepam and vicodin immediately prior to the procedurediazepam and vicodin immediately prior to the procedure 46. Conclusions: Submental ST & ProlipoConclusions: Submental ST & Prolipo Combination BBL:ST and ProLipo with laser followed by immediateCombination BBL:ST and ProLipo with laser followed by immediate liposuction isliposuction is safe and operator dependentsafe and operator dependent technique for improvingtechnique for improving submental contoursubmental contour BBL:BBL:ST should be performed prior toST should be performed prior to local-injectionlocal-injection anesthesiaanesthesia Laser without liposuction leads to unacceptable swellingLaser without liposuction leads to unacceptable swelling due to thedue to the inflammatory effect of lysed fat cell products in the intercellularinflammatory effect of lysed fat cell products in the intercellular space. However, it can achieve significant contour improvementspace. However, it can achieve significant contour improvement A further study comparing BBL alone with, liposuction alone, versusA further study comparing BBL alone with, liposuction alone, versus combined BBL, laser and liposuction alone is warrantedcombined BBL, laser and liposuction alone is warranted.. 47. Be joyful while we are young Gaudeamus igitur juvenes